Comprehensive evaluation of Medtronic’s Butterfly platform, a new audiovisual information material for patient education and shared decision-making in surgical thyroid disease

Comprehensive evaluation of Medtronic’s Butterfly platform, a new audiovisual information material for patient education and shared decision-making in surgical thyroid disease | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comprehensive evaluation of Medtronic’s Butterfly platform, a new audiovisual information material for patient education and shared decision-making in surgical thyroid disease Maria Moschofidou, Grégoire Racine, Ilaria Giordani, Dionysios V. Chartoumpekis, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7309071/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Apr, 2026 Read the published version in BMC Medical Informatics and Decision Making → Version 1 posted 9 You are reading this latest preprint version Abstract Background To facilitate shared decision-making, patients increasingly rely on online platforms for health-related information. While thyroid diseases are common, the quality of available thyroid-related information varies. This study comprehensively evaluated a new audiovisual information material developed by Medtronic for patients with surgical thyroid disease in English and French. Methods Data were collected from patients at baseline (t1), after accessing the French version of Medtronic’s Butterfly platform but before surgery (t2), and three weeks post-surgery (t3). Patients assessed the material’s usefulness (USE), impact (eHIQ) and quality (Brief DISCERN), provided feedback on its content using a custom debriefing questionnaire, and self-reported on their anxiety (GAD-7), depression (PHQ-9) and stress (PSS-14). We assessed both versions for readability (FRES, FKGL, SMOG, GFI, and Scolarius); understandability and actionability (PEMAT-A/V); linguistic aspects (LIWC-22) and tone style (YesChat Tone Analyzer). In addition to conducting quantitative and qualitative analyses of the respective datasets, triangulation was used to integrate both approaches. Results Of 26 patients enrolled, 24 (t2), and 22 (t3) completed the study; both benign and malignant/potentially malignant surgical indications were represented. The material’s scores regarding usefulness and impact at t2 were both significantly above the respective predefined thresholds. Consistently, qualitative analysis showed that most participants found the material useful or very useful. Whereas anxiety and depression scores were low across t1-t3, levels of stress were consistently high, and a negative correlation between USE and GAD-7 scores suggested that greater perceived usefulness is associated with lower anxiety levels. Even though readability scores for both languages indicated higher complexity than the generally recommended 6th -8th grade level, neither the quantitative nor the qualitative feedback of patients indicated challenges with the material’s language. Assessment of the material by five investigators showed very good understandability and excellent actionability. Linguistic analysis showed a somewhat higher complexity of the French version; for both versions, tone analysis reported a clear, approachable, and professional style, with direct and informative content, using generally simple language. Finally, participants suggested slight improvements, especially regarding online navigation. Conclusions Medtronic’s Butterfly platform is a high-quality information source to aid shared decision-making in patients with surgical thyroid diseases. preoperative information patient education audiovisual information material thyroidectomy e-health shared decision-making Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION Thyroid diseases alter the anatomy and/or impair the functionality of the thyroid gland, leading to detrimental effects on patient health and health-related quality of life (HRQoL). Their prevalence among adults in Westerns societies is around 6.6% [ 1 – 3 ], and it is higher among women and older individuals. Despite efficient diagnostic tools and treatments and a generally favorable prognosis, thyroid dysfunction adversely impacts HRQoL even in benign thyroid disorders [ 4 , 5 ]. Similarly, despite an excellent overall prognosis in the majority of cases, thyroid cancer survivors also experience a reduction in their HRQoL [ 6 , 7 ]. Surgery is a critical moment in the trajectory of many patients with benign or malignant thyroid disease, because patient experience, surgical complications and other outcomes can have a major impact on HRQoL [ 8 – 10 ]. Thyroid surgery may be indicated for patients with thyroid cancer, large nodules that cause symptoms, nodules with a malignant, suspicious or indeterminate cytology [ 11 ], or conditions that cause hyperthyroidism [ 12 ]. Patient education is crucial in the decision-making of patients undergoing thyroid surgery to help them understand the procedure and its associated risks and benefits, potential alternatives to surgery, technical means to minimize complications, priorities in postoperative care, etc. [ 10 , 13 ]. This is consistent with studies in other medical fields showing that effective educational interventions can foster cooperation and improve postoperative outcomes [ 14 ]. In general, well-informed patients tend to experience less anxiety and more satisfaction with care, and they adhere better to postoperative instructions [ 14 – 17 ]. The use of information technology (IT) platforms to enhance patient engagement and provide accessible health information addressing the knowledge needs of patients and their families is a recognized application of medical informatics. Online patient information materials are highly relevant to shared decision-making in healthcare, and studies indicate that approximately 70% of patients prefer accessing health information online, highlighting the need for effective digital resources [ 18 ]. By improving understanding of risks, benefits, and possible consequences of different choices, online patient information materials support more informed and personalized decisions [ 19 – 22 ]. They thus facilitate communication and empower patients to participate more actively and confidently in discussions with their healthcare providers (HCPs), and to articulate their preferences, values, and concerns. In these ways, online patient information materials help to shift the care model from physician-dominated to collaborative and patient-centered [ 23 ]. Challenges associated with such materials include their variable quality, reliability and accuracy, that may sometimes lead to misinformation or misunderstanding, as well as potential deviations from the information provided by HCPs that can lead to confusion or conflict [ 24 – 26 ]. These general principles and concerns also apply to the online information on thyroid diseases. Such information is often incomplete, particularly on critical topics such as diagnosis and treatment [ 27 ]. For example, a study evaluating online information for the treatment of low-risk thyroid cancer indicated that most websites failed to incorporate updates from the 2015 American Thyroid Association (ATA) guidelines, and they often lacked essential details about treatment options necessary for informed decision-making [ 28 ]. Further, a review by the National Institute for Heath and Care Excellence (NICE) found high-quality evidence from 3 studies highlighting patients’ need for further information, and emphasized that the lack of sufficient verbal information provided by health professionals may lead patients to potential online misinformation [ 29 ]. A study assessing patient information on thyroid cancer concluded that the quality of the respective websites is highly variable, with a predominance of low-quality content, highlighting the need for improved visibility of trustworthy sources and enhanced e-health literacy among patients [ 30 ]. These findings are consistent with a study that identified the information provided as an area for improvement even among thyroid cancer patients who were generally satisfied [ 31 ]. Indeed, an analysis of unmet information needs among thyroid cancer survivors showed that a significant proportion reported insufficient understanding before treatment [ 32 ]. Such findings indicate that, even though online resources cannot replace the information provided orally by HCPs, their quality, content and accessibility are essential to support informed decision-making and improve health outcomes. The present study performed a comprehensive evaluation of the Medtronic Butterfly platform, a new e-learning tool for patients undergoing thyroid surgery. The results indicate that patients perceived the material to be beneficial, with positive effects on their knowledge and ability to take action, including their participation in shared decision-making. METHODS The Medtronic Butterfly platform The Medtronic Butterfly platform is an innovative e-learning tool designed to enhance education for patients undergoing thyroid surgery. The platform was developed in collaboration with a multidisciplinary group of surgeons, endocrinologists, and patient advocacy organizations. Its goal is to improve patients’ understanding of their thyroid conditions and the procedures they may undergo by offering (i) learning modules on thyroid conditions and treatments; (ii) step-by-step guides to surgical procedures and recovery expectations; (iii) insights into thyroid surgery; and (iv) post-surgery advice on managing recovery and adjusting to life after thyroid surgery. The co-construction process will be described in detail elsewhere. The platform is freely accessible online in English [ 33 ]; the French version is in the process of being made available. The platform's main menu comprises five sections with written information: “Understanding your condition, diagnosis and treatment options”; “Getting ready for your hospitalization”; “Understanding your hospitalization and surgery”; “Next steps and advice for the recovery period”; and “Post-surgical treatments”. Additionally, the platform features five educational videos: “What is the thyroid?”; “Diagnostic process”, “Understand the surgery; Thyroid Surgery”; “Understand your hospitalization”; “Taking care of your scar”. To complement this information, three downloadable leaflets provide practical guidance: “What to pack for my hospital stay”; “Pre-admission checklists”; and “Recommendations for recovery”. This structure provides a comprehensive overview for patients, ensuring they are well-informed about their condition, the surgical process, and the post-operative care. Study objectives, outcome measures, instruments, and schedule of assessments The main objective of this single-arm cohort study was to perform a comprehensive evaluation of Medtronic’s Butterfly platform. The outcome measures, instruments, and schedule of assessments are indicated in Table 1 . The main primary outcome measures were the material’s impact on patients undergoing thyroid surgery and its usefulness for these patients; further primary outcome measures were the material’s quality, content, readability, understandability and actionability. Secondary outcome measures were the patients’ levels of stress, anxiety and depression, and their potential correlation with the material’s impact and usefulness. The instruments used had been previously validated, except for the custom debriefing questionnaire used to assess the content; this was based on items developed from a literature review, and it was pilot tested with the first 5 study patients. For the eHIQ instrument, we produced a cross-culturally validated French translation in strict adherence with the methodology recommended by Oxford University; the French version is now officially available for use by others [ 34 ]. Table 1 Outcome measures, instruments and schedule of assessments. Questionnaires Variables Evaluators Time points t0 t1 t2 t3 USE Usefulness Patients + + e-HIQ Impact Patients + + GAD-7 Anxiety Patients + + + PHQ-9 Depression Patients + + + PSS Stress Patients + + + Brief DISCERN Quality Patients + Debriefing Content Patients + CRF-t1 Sociodemographic and clinical data Investigators + CRF-t2 Investigators + CRF-t3 Investigators + FKGL, GFI, SMOG, FRES, Scolarius Readability Investigators + PEMAT-A/V Understandability Investigators + PEMAT-A/V Actionability Investigators + LIWC-22 Linguistic Analysis Investigators + YesChat Tone Analyzer Tone Style Analysis Investigators + t0: study enrolment; t1: before accessing the materials, 0–2 weeks after t0; t2: 0–2 weeks before surgery; t3: 2–4 weeks after surgery; USE: Usefulness Scale for Patient Information Material; eHIQ: e-Health Impact Questionnaire; GAD-7: Generalized Anxiety Disorder-7; PHQ-9: Patient Health Questionnaire-9; PSS: Perceived Stress Scale; CRF: case report form; FKGL: Flesch-Kincaid Grade Level; GFI: Gunning Fog Index; SMOG: Simple Measure of Gobbledygook; FRES: Flesch Reading Ease Score; PEMAT-A/V: Patient Education Materials Assessment Tool for Audiovisual Materials; LIWC-22: Linguistic Inquiry and Word Count. The material’s readability, understandability and actionability were assessed by the investigators using validated tools, without involving patient participation. Sociodemographic and clinical data were collected at study enrolment (t0), and other parameters were assessed by patient-users before accessing the material (t1, 0–2 weeks after t0), after accessing the material but prior to surgery (t2, 0–2 weeks before surgery), and post-surgery (t3, 2–4 weeks after surgery). The duration between t1 and surgery varied, with a minimum interval of two weeks. At t1, patients completed 3–7 questionnaires in person, with assistance from a doctoral student if necessary, and was then given access to the information material via a hyperlink. At t2 and t3, questionnaires were mailed to participants, who returned them using pre-paid envelopes. Study participants and sample size calculation Eligible patients were adults who could understand and complete questionnaires in French, were able to use online resources via a computer, tablet or cell phone, and had an indication for thyroid surgery for either benign thyroid disease (Graves’ disease or benign nodules/goiter) or for suspected (indeterminate or suspicious cytology) or confirmed thyroid cancer. Patients were excluded if they were unable to follow procedures or provide consent or had had prior thyroid surgery. Patients were recruited at Lausanne University Hospital by proposing the study to all eligible patients between May 2022 and May 2023. The study was performed in accordance with the Declaration of Helsinki; it was approved by the Cantonal Commission on Ethics in Human Research of Vaud (Swiss Business Administration System for Ethics Committees identification number 2022 − 00395), and all patients provided written informed consent. The target sample size was calculated for the main primary outcome of impact, hypothesizing a mean score of at least 5 points (medium effect size) above the 65-point threshold for good impact in Part 2 of the eHIQ questionnaire [ 35 ]. For a one-sample t-test, two-tailed significance p-value < 0.05 and statistical power of 80%, G*Power [ 36 ] calculates a sample size of 27 patients, yielding an actual power of 83.6%. Data handling and statistics Data management was conducted using REDcap 14.0.12, and quantitative analyses were performed with GraphPad Prism 9.5.1 (GraphPad, San Diego, CA). For the main primary outcomes (eHIQ and USE scores), data were analyzed using one-sample t-test. For comparison of outcomes at different timepoints, data were analyzed using paired t-test (two timepoints; eHIQ and USE scores) or one-way repeated measures non-parametric ANOVA (three timepoints; GAD-7, PHQ-9 and PSS-14 scores). For comparisons between different patient groups, data were analyzed using paired t-test. For simplicity of presentation, data (e-HIQ) were rounded to the nearest integer. Data on the material’s content (debriefing questionnaire) were analyzed qualitatively using Clarke and Braun's six-step process for thematic analysis [ 37 ]. Data triangulation was achieved through the integration of quantitative and qualitative data, including also linguistic aspects (LIWC-22, quantitative) and tone style (YesChat Tone Analyzer, generative artificial intelligence). RESULTS Patient cohort A total of 54 potential participants were initially contacted; after screening, 48 met the enrolment criteria, among whom 28 agreed to participate (58% acceptance rate). Two were excluded at t0 due to changes in their treatment plan; of the 26 participants, 22 completed the study (there were 2 dropouts before t2 and two before t3; 15% total dropout rate). The mean and median age of participants was 50 and 49 years, respectively (standard deviation 14.76, range 20–75); and 17 (65%) were female. Operations planned were total thyroidectomy (n = 12, 46%) and lobo-isthmectomy (n = 14, 54%). All types of surgical indications were represented: Graves’ disease (n = 3, 12%), benign thyroid nodule (n = 7, 27%), thyroid nodule with cytology results that were indeterminate (Bethesda III or IV) or suspicious for malignancy (Bethesda V) (n = 11, 42%), and thyroid cancer (n = 5, 19%). Nearly half (n = 12, 46%) of the patients reported that the disease was detected due to symptoms; in 5 patients (19%), diagnosis was secondary to detection of a neck lump, and in 9 (35%) it was an incidental finding on imaging. Only 5 participants (19%) had an education level below USA grade 9. Usefulness The Usefulness Scale for Patient Information Material (USE) instrument, employed to assess the written part of the audiovisual information material (i.e., the webpages, forms and memos, excluding the videos), comprises three subscales (cognitive, emotional and behavioral), with 3 questions per subscale [ 38 ]; each question is scored from 0–10, yielding a total score of 0–90, with higher scores indicating higher perceived usefulness. Because there is no formal threshold for a highly useful material, we set a threshold of 60/90 points (67%, in analogy with the 65% threshold of the eHIQ instrument – see below). Results are shown in Fig. 1 . Among the patients who completed the questionnaire at t2 (n = 24) and t3 (n = 22), the mean total score for usefulness was 66 ± 10 (range 53–85) at t2 and 66 ± 15 (range 20–86) at t3 (Fig. 1A); despite variable trends for individual patients, there was no significant difference in total scores between t2 and t3. The single outlier who indicated the lowest scores across all subscales at t3 explained that the information provided did not match well her lived experience. These results indicate that a one-time assessment of the material would have been sufficient overall, probably before surgery (t2), when patients are most likely to consult the material in clinical practice. This is consistent with the observation that the mean usefulness scores were significantly above the threshold at t2 (one-sample t-test, p = 0.0087) but not at t3 (p = 0.1078), noting again the single outlier. Nevertheless, at both t2 and t3, most patients gave scores above the threshold: 15/24 (63%) at t2 and 16/22 (73%) at t3. Patterns in the three subscales were like the total scores (Fig. 1B-D). Most patients scored in the upper half of the range, and there were no significant differences in scores between t2 and t3 in any of the subscales: cognitive, 24 ± 4 (range, 17–30) at t2 vs. 24 ± 5 (range,14–30) at t3; emotional, 21 ± 4 (range, 12–27) at t2 vs 20 ± 6 (range, 2–28) at t3; and behavioral, 21 ± 4 (range, 15–30) at t2 vs. 21 ± 6 (range, 4–30) at t3. Taken together, these findings indicate that the written part of the information material was useful for most patients before surgery, especially at the cognitive level, but also at the emotional and behavioral levels. Impact The eHIQ instrument comprises two parts; the first one assesses patients’ general attitudes toward using the internet to access health information, and the second assesses patients’ attitudes towards the specific information material under study. The mean scores in Part 2 were 74 ± 9 (range, 52–91) before surgery and 69 ± 10 (range, 50–93) after surgery (Fig. 2E). The score at t2, but not at t3, was significantly above the threshold of 65/100 points (p = 0.0087 and p = 0.1078, respectively). The percentage of patients who gave scores ≥ 65 was 75% at t2 (18/24) and 73% at t3 (16/22). These results reflect positive attitudes towards the new information material among patients preparing for surgery. Even though there was a significant positive correlation of Part 2 scores before and after surgery (r = 0.646, p = 0.001), mean scores after surgery were significantly (albeit slightly) lower than before surgery (p < 0.0001); this indicates that the overall perceived impact of the new information material is highest before surgery. Lastly, there was a positive correlation (r = 0.43, p = 0.035) between pre-surgery usability scores (USE at t2) and perceived impact of educational materials (eHIQ-Part 2 at t2), indicating that participants who rated the materials as more usable also reported good impact. This highlights that usability plays a role in enhancing the overall effectiveness of educational tools and provides confidence in the use of both instruments as orthogonal measures to assess the new material’s usefulness and impact. We also explored whether the impact of the new information material (as reflected in the eHIQ-Part 2 score) varied according to patient characteristics (gender, type of surgical indication, and education level). No significant differences were found, acknowledging however the small size of some of the subgroups (Fig. 3). Part 2 comprises three subscales: “confidence and identification” assesses the self- confidence of patients regarding the material; “information and presentation” assesses trust and suitability of the material; and “understanding and motivation” assesses self-efficacy to determine whether patients were motivated to take action based on the information presented. The respective mean scores before and after surgery were 68 ± 10 (range 44–92) vs. 64 ± 10 (range, 44–86), 80 ± 10 (range 56–97) vs. 72 ± 12 (range, 50–97), and 72 ± 11 (range, 53–97) vs. 70 ± 11 (range, 50–97) (Fig. 2F-H). The fact that the scores are highest for “information and presentation” is not surprising, because it is arguably easier to present information than to inspire trust or motivate action. Nevertheless, the findings indicate that the information material has a positive impact on all these aspects. Similarly, the results from USE showed a higher impact regarding the level of knowledge compared to the other subscales (Fig. 1B-D). Finally, the lower overall Part 2 scores at t3 compared at t2 (Fig. 2E) seem to be due to the significantly lower scores in the subscale “information and presentation” (p = 0.0026) (Fig. 2G). This suggests that the perceived impact of the new information material decreases after surgery mainly because the perceived relevance of the procedure-related information is lower. The extent to which the information provided matched a particular patient’s actual lived experience may also play a role, at least for some patients. Part 1 comprises two subscales: the first one assesses attitudes towards online health information in general, including factors such as readability, trust, and making decisions based on online information; and the second assesses attitudes towards sharing health experiences online. Before surgery, the mean score for the first subscale was significantly lower compared to the second one (52 ± 14 vs. 59 ± 15, p = 0.024), with both being below the threshold of 65 points (Fig. 2C-D). These findings suggest that patients in the present study had a lower initial inclination towards using the internet for general health information and were somewhat hesitant to trust it, even though they were somewhat more open to sharing their health experiences online. After surgery, the scores for the first and second subscale were 57 ± 18 and 62 ± 13, respectively (Fig. 2C-D). There was thus a significant increase in general attitudes towards online health information (p = 0.033), with no significant difference in inclination towards sharing experiences with others online. This indicates that use of the new material increases patients’ trust on the internet as a source of health-related information, which is a very positive finding regarding the material’s impact. Conversely, the absence of an effect on inclination towards sharing experiences with others online is expected, because use of the material does not entail such interactions. There was a significant, moderate positive correlation between the scores in Part 1 and Part 2 at t2 (r = 0.54, p < 0.0001). However, Part 2 scores were significantly higher than Part 1 scores at both t2 and t3 (p < 0.0001; Fig. 2B, 2E) . This indicates that the new material was appreciated by the participants, and that this positive impact was achieved despite the generally reserved initial (and later) attitudes towards using the internet for health information. Anxiety (GAD-7), depression (PHQ-9) and stress (PSS-14) Anxiety seems to vary substantially between participants. Among the patients who completed the study, the mean GAD-7 scores at the various time points were very similar: 5 ± 6 at (t1), 5 ± 5 at (t2), and 4 ± 5 at (t3) (p = 0.73) (Fig. 4A), with respectively 3, 2 and 4 patients scoring above the threshold of ≥ 10 points that indicates at least moderate anxiety [ 39 ]. In some participants there seemed to be an upward trend after access to the material and a downward trend after surgery (Fig. 4A); this might be related to the fact that these participants completed their questionnaire very close to the day of surgery. Finally, one participant had a low level of anxiety before surgery that increased markedly after surgery (Fig. 4A); in the debriefing questionnaire she stated that she had not actually experienced what the information material described. PHQ-9 scores also varied substantially between patients, with some showing extreme variations that are difficult to explain. With few exceptions, most patients did not appear to have symptoms of depression; mean scores were 7 ± 6 at t1, 6 ± 5 at t2, and 6 ± 4 at t3 (Fig. 4B). A total of 5 patients at each time point had a score ≥ 10 indicating at least moderate depression [ 40 ]. Similar to GAD-7 scores, there were no significant differences in PHQ-9 scores over time. PSS-14 results indicated moderate to high perceived stress levels among the patients throughout the study. Mean scores were 32 ± 6 at t1, 30 ± 7 at t2, and 30 ± 5 at t3 (Fig. 4C). Across the time points, all scores but one (at t2) were ≥ 19, indicating at least moderate levels of perceived stress, and a total of 2 patients at each time point had a score ≥ 38 indicating high stress [ 41 ]. Similar to GAD-7 and PHQ-9 scores, there were no significant differences in PSS-14 scores over time. Correlations were examined between these three psychological measures at t1 and the two impact measures (USE and eHIQ-Part 2 scores) at t3. A significant positive correlation was observed between GAD-7 and eHIQ-Part 2 scores (r = 0.457, p = 0.032), suggesting that the material has more impact on patients with higher basal anxiety levels. Further, a significant negative correlation was observed between PHQ-9 and USE scores (r=-0.504, p = 0.010), suggesting that the perceived usefulness of the material is lower among patients with higher basal depression levels. Quality (Brief DISCERN) The Brief DISCERN is a simple, six-question tool designed to help patients and consumers quickly assess the quality of health information on the web, especially regarding treatment choices [ 42 ]. Among the 22 patients, 21 completed the instrument at the end of the study (t3). The majority (19/21, 90%) gave scores > 16, with 14/21 (67%) giving a maximum score of 30; the mean score was 25 ± 8 (Fig. 5). These data indicate a very good content quality of the new audiovisual material [ 42 ]. The main reason for lower scores is primarily due to the second question, which assesses the clarity of publication dates and identifiable sources. In this regard, 7 patients correctly pointed out that the publication dates were not mentioned. Content (custom debriefing questionnaire) The Debriefing Questionnaire provides comprehensive feedback through closed-ended (e.g., Likert scale, yes/no) and open-ended questions, assessing clarity, usefulness, satisfaction, and difficulties, while also inviting suggestions or additional comments ( Supplementary Table 1 ). The vast majority of patients (87%) indicated that they found the material useful or very useful, and none found it not at all useful. At the emotional level, patients reported that the material made them feel calm, relieved, confident, reflective and curious. All patients indicated trust in the source of the material and believed that the information provided is accurate and reliable. Their main topics of interest were thyroid function, what is going to happen, preparation for hospitalization, and the post-hospitalization period. Except for two patients, the information provided reportedly corresponded to what actually happened. No information was identified as upsetting or difficult to understand. Patients found the material useful because it was (i) clear and concise (e.g., “the content is good for informing about the disease”); (ii) relevant and applicable (e.g., “explanations of my case”); (iii) accessible (e.g., “the format is perfect”); and (iv) empowering (e.g., “useful to know the logical sequence of events to better prepare me”). On the other hand, some patients indicated aspects that could be improved: (i) limited scope, not comprehensive enough to address all possible health concerns or conditions that patients may have (e.g., “I was in stress to find information on exophthalmos, and I was disappointed not to find any”, “I would have liked to see more examples of recommended foods”); (ii) technical difficulties (e.g., “It's hard to read on a cell phone. I had to use a tablet. The font size is very small”, “The structure is well done but I sometimes got lost to find a page that I wanted to review”); (iii) language and cultural barriers (e.g., “My suggestion is to subtitle the videos so that non-French speaking patients can understand better. Then the text can be summarized"; (iv) contradictions with their lived experience (e.g., “At the hospital I was advised to take the calcium 2 hours after the thyroid hormone and on the site, it is a 4-hour delay”, “I feel little scared because the doctor had not explained all the details to me”). Overall, the most common comments for improvement concerned requests for subtitles, improved navigation, and additional nutritional advice. Readability The complexity of the written text was evaluated for each section using four established readability formulas [Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG), and Gunning Fog Index (GFI)], and the corresponding grade and reading level were calculated [ 43 ]. For the French version, the French-specific tool Scolarius was also employed [ 44 ]. As recommended for readability analyses, texts were pre-formatted for analysis in a standardized manner, including removal of bullet points and headings [ 45 ]. The results (Table 2 ) show that both language versions are written at a higher complexity than the generally recommended 6th -8th grade level [ 46 ], with only one (French version) or two (English version) sections meeting recommendations. Most sections (14/18) showed higher complexity in the French version compared to the English one (Table 2 ); this is consistent with what has been observed for other patient information materials [ 47 , 48 ], and it may be related to the differences in language structure and/or their treatment by the readability formulas [ 45 ]. An extreme difficulty indicated by Scolarius for section “12. Pre-admission check list” is likely skewed due to its check-list format, considering that it is scored as standard by the other tools. Despite the higher complexity of the texts compared to recommendations for patient-oriented materials, neither the quantitative nor the qualitative feedback of patients highlighted challenges with the material’s readability; for example, even though most participants’ (21/26, 80.77%) educational level was above the 8th grade, all participants agreed or fully agreed that “the language used by the website made it easy to understand” (eHIQ-Part 2 question 6). Table 2 Readability analysis results per section of the English and French versions. English version French version Section FKGL GFI SMOG FRES Grade Reading level FKGL GFI SMOG FRES Grade Reading level Scolarius 1. Understand my condition 9.1 10.6 11.8 56.8 10th somewhat difficult 11.9 14.6 13.8 40.1 12th difficult 124 college 2. Understanding the diagnostic process 8.8 10.3 11.5 57.4 11th fairly difficult 12.1 14.4 13.7 33.8 12th difficult 139 college 3. Understand the treatment options 12.1 14.4 13.7 33.8 11th fairly difficult 11.6 13.9 13.2 35.7 12th difficult 120 college 4. Questions to ask to your surgeon 11.6 13.9 13.2 35.7 11th fairly difficult 6.7 9.1 13.2 61.8 7th average 57 primary 5. Understand the surgery - The thyroid 10.4 13.9 13.6 50.1 11th fairly difficult 12.3 14.8 14.0 36.3 college entry very difficult 138 college 6. What will happen before your surgery 11.2 14.1 13.3 50.3 11th fairly difficult 14.3 16.5 15.2 28.0 12th difficult 153 university 7. Medication advices 14.4 18.2 16.3 28.5 college professional 16.0 18.7 16.4 15.1 college entry very difficult 142 college 8. Understand my hospitalization 8.5 11.6 11.8 36.5 10th somewhat difficult 11.9 14.4 13.5 38.6 11th fairly difficult 115 secondary 9. What are the next steps after surgery 11.0 13.4 13.1 46.1 12th difficult 13.0 15.6 14.4 32.3 12th difficult 138 college 10. What to pack for my hospital 9.1 9.1 11.8 52.0 12th difficult 11.3 13.9 13.4 38.4 11th fairly difficult 168 university 11. How to manage anxiety 7.5 10.6 11.0 67.9 8th average - slightly dif. 11.4 13.2 13.1 42.7 10th somewhat dif. 174 university 12. Pre-admission check list 7.5 10.6 10.9 64.7 8th average - slightly dif. 11.2 13.7 13.7 42.5 10th somewhat dif. 329 initiated 13. Managing pain after your surgery 10.7 13.4 13.1 56.1 11th fairly difficult 13.9 16.6 15.2 33.2 college entry very difficult 159 university 14. Instruction for scar care after surgery 13.9 16.6 15.2 33.2 10th somewhat difficult 13.8 16.3 15.2 34.2 12th difficult 144 college 15. Managing your weight after surgery 9.1 11.3 11.7 58.7 11th fairly difficult 11.8 14.5 13.9 39.9 12th difficult 108 secondary 16. Recovery period recommendations 8.4 11.1 11.4 61.5 9th slightly difficult 12.1 14.8 13.9 36.4 11th fairly difficult 117 secondary 17. Hormone treatment 8.9 11.2 11.6 56.3 10th somewhat difficult 12.1 14.4 13.8 35.8 11th fairly difficult 157 university 18. Radioactive iodine treatment 10.7 13.2 12.8 47.9 12th difficult 13.4 15.9 14.6 30.6 college entry very difficult 134 college The Flesch-Kincaid Grade Level (FKGL) indicates the U.S. grade level needed to understand the text, with lower scores indicating easier readability; the Gunning Fog Index (GFI) estimates the years of formal education needed to understand the text on first reading, with lower scores indicate easier readability; the Simple Measure of Gobbledygook (SMOG) estimates the years of education needed to understand a piece of writing, with lower scores indicating easier readability; the Flesch Reading Ease Score (FRES) scores text on a 100-point scale, with higher scores indicating easier readability; and Scolarius provides a comparison to other texts of the same type, with lower scores indicating easier readability. Understandability and actionability (PEMAT-A/V) The Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-A/V) was used to evaluate the understandability (13 questions) and actionability (4 questions) of the educational material. Five investigators independently conducted the assessment, discussing and resolving uncertainties wherever relevant. Results showed a perfect actionability score of 100% and an understandability score of 82% that exceeded the 70% threshold, indicating a high-quality material (Fig. 6). The inter-rater reliability, measured by Fleiss Kappa, indicated fair agreement among the five reviewers (κ = 0.39, p < 0.001). The material demonstrated strengths in understandability through well-structured information, effective visual aids, and use of everyday language; contextualization of the latter should consider that the investigators were HCPs. Areas where understandability could be improved were also identified: a summary was lacking; there was sometimes too much text on a single page, making it difficult to read; better use of illustrations could reduce text density; there were minor inconsistencies in terminology and occasional typographical errors; topic separation could be improved and section transitions could be clearer; and some anatomy- and insurance-related terms should be culturally adapted (for a Swiss audience). These findings suggest that while the material is largely comprehensible and perfectly actionable, targeted refinements could further enhance its understandability. Linguistic analysis and tone style analysis The Linguistic Inquiry and Word Count is a validated scientific tool specifically designed for text analysis, used to extract linguistic, psychological, and social insights from written or spoken text. To analyze the English and French versions of the material, we used the latest version (LIWC-22) and its respective dictionaries [ 49 , 50 ]. The French text was longer than the English one (15.457 words vs. 14.612, respectively), despite an identical number of words per sentence (n = 22). It also had a higher percentage of “big words” (32% vs. 25%, respectively); this refers to words with ≥ 7 letters, which is a proxy for text complexity, reflecting the use of advanced vocabulary or formal language. LIWC-22 could calculate percentages for psychological or linguistic dimensions (LIWC Summary Measures) only for the English version; besides, the percentage of text words present in the respective dictionaries were 87% for the English text and only 73% for the French one, indicating that the former aligns better with LIWC's analytical framework. Results for the specific LIWC Summary Measures, expressed as percentiles, were as follows: (i) Analytical thinking: 57, indicating an intermediate degree between a hierarchical and structured communication and a more narrative, intuitive, and informal style. (ii) Clout: 84, indicating a confident, authoritative, and leadership-oriented communication style in which the writer feels secure in their knowledge. (iii) Authenticity: 36, indicating a text that is more socially cautious, formal, or pre-prepared. (iv) Emotional tone: 32, suggesting a more negative or downbeat sentiment, marked by frequent use of negative emotion words. Indeed, the percentages of emotion-positive and emotion-negative words in the English version were 0.23% and 0.64% respectively. Interestingly, in the French version, the respective percentages were 2.41% and 2.13%; this discrepancy likely reflects linguistic and cultural differences in expression. Finally, to obtain a more comprehensive and qualitative analysis of the material’s tone and style, the English and French versions were analyzed using YesChat Tone Analyzer [ 51 ]. The results (Table 3 ) show that the content effectively maintains a neutral and informative tone, using clear language to educate readers about thyroid function and related medical-surgical procedures. In both versions, the tone, style, voice and linguistic patterns are suitable for patient education, balancing professionalism, empathy and accessibility to inform without causing alarm or confusion. Some distinct tonal and grammatical differences emerged, with the English version being more direct and conversational, creating a friendly and personal atmosphere to foster intimacy and reassurance. In contrast, the French version adopts a more formal and polite tone including passive constructions that result in a courteous but detached tone, emphasizing respect and education over emotional engagement. Ultimately, both versions engage the reader, but the English text establishes a warmer connection, while the French text maintains formality and respect, which also likely relates to linguistic and cultural differences. Table 3 Results of the tone style analysis of the text in the English and French versions. English version French version Tone Calm, reassuring and educational. Blends clinical accuracy with empathetic clarity. Reassuring, instructive and compassionate. The text anticipates patient anxiety and responds with warmth and clarity. Style Formal yet accessible; uses structured headings, bullet points, and short paragraphs for readability. Comprehensive and didactic, broken into structured headings and subheadings for ease of navigation. Uses bullet points, analogies and diagrams or placeholders to support explanation. Voice Neutral, informative, and professional. Consistently uses second person (“you”) to engage readers and personalize complex medical explanations. Empathetic and authoritative. Speaks directly to the reader (“you”) in a professional yet human-centered manner. Linguistic patterns Definitions followed by examples or analogies; use of parenthetical clarification (e.g., "also known as T3"). Emphasis on demystifying technical terms. Gentle encouragement to ask questions, reduce anxiety, and participate in care. Softened clinical language (e.g., “not too painful,” “mild hoarseness”) to reduce fear. Frequent use of parenthetical definitions (e.g., “T3 – triiodothyronine”). Mild repetition for reinforcement. Soothing language when referring to sensitive topics (e.g., cancer, surgery, biopsy). Present tense and active voice to maintain immediacy and support understanding. Occasional rhetorical questions to engage the reader (e.g., “What is an endocrinologist?”). Step-by-step procedural outlines to reduce uncertainty and build trust. DISCUSSION The present comprehensive assessment of the Medtronic Butterfly educational platform providing information to patients with surgical thyroid disease documented numerous strengths of the new material and identified some areas for improvement. The patients’ feedback underscored the usefulness and positive impact of the material, particularly prior to surgery. Indeed, despite the low tendency of the participants to use the internet for general health information and their general hesitation to trust online resources, patient trust and suitability of the material were very highly scored. The patients assessed the written information as high-quality, an aspect known to play a pivotal role in its effectiveness. Assessment of the material’s understandability and actionability by the medical professionals showed that the content is not only very informative but also highly practicable, with a perfect actionability score. Qualitative analysis of patients’ feedback confirmed that the material exhibits satisfactory clarity and comprehensibility. Importantly, in most cases, the information provided regarding surgery corresponded to what actually occurred. The absence of upsetting or difficult to understand information also contributed to the material’s effectiveness. Further, analysis of the text using informatics tools revealed a neutral and informative tone, with clear, balanced, accessible and empathetic language that is suitable to educate and reassure patients. Factors known to influence engagement with web-based healthcare information include comprehensibility, support, adaptability, accessibility, visual appeal, content quality, and credibility [ 52 ]; the platform’s performance was overall well-rated regarding such aspects. In general, young adults find the video format easy to learn from [ 53 ], and the platform’s videos were systematically viewed and well appreciated according to patient feedback. In addition to digital and health literacy, concerns about privacy represent barriers to the adoption of digital health technology [ 54 ]; no such concerns were raised by the participants, which was reassuring. Among areas for potential improvement, the main one was the readability of the material, which was assessed as more advanced than the recommended level (6th -8th grade) [ 55 ]. Accordingly, the material should ideally be written in even simpler language. However, readability formulas may not be optimal for patient education materials [ 56 , 57 ], such as names of active substances that were included in the present material. Indeed, patients' quantitative and qualitative feedback did not indicate any issues with the readability of the material. Rather, participants were mostly concerned with difficulties in webpage navigation in relation to the main menu structure, even though the overall usability remained satisfactory. The material was specifically reported as difficult to view on smartphones, particularly due to size limitations. Interestingly, even though all users consulted the web pages and videos, more than half indicated they did not utilize the available downloadable documents. While the margin to further adapt the material for smartphones may have its limits, optimizing navigation on tablets or computers should be readily feasible. Further improvements could be made to enhance understandability, e.g., include a summary and shorten some texts; cultural relevance could also be considered regarding notably insurance-related terms; and some patients indicated a desire for additional dietary advice. Finally, the results showed low levels of anxiety or depression but high levels of stress among participants, which persisted even after surgery. Even though the linguistic and tone analysis showed that the text was suitable to reassure patients, the material does not address explicitly high stress levels, and therefore physicians who recommend it to their patients should consider other resources for anxiety management, such as referral to a psychologist, if needed. A key strength of this study is the use of multiple tools, both quantitative and qualitative, to evaluate various relevant aspects of the new educational material. In addition to achieving a comprehensive assessment, this also facilitated the cross-validation of the main findings; for example, the high understandability and actionability assessed by the investigators in PEMAT-A/V mirrored the high level of understanding and motivation indicated by the patients in eHIQ Part 2. Similarly, there was clear correspondence between patients’ responses in USE, eHIQ Part 2 and the qualitative debriefing questionnaire, as well as between these three questionnaires and the automated results of the linguistic and tone analysis by informatics tools on respective aspects. These consistencies among the assessment results by patients (providing genuine insights and feedback about their experiences), researchers (maintaining scientific rigor in the methodology) and informatics tools (avoiding bias) strongly support the internal validity of the present evaluation, as does the overall stability of the vast majority of responses across the respective time points. One limitation of the study is the small sample size, with 22/26 patients completing the study (drop out-rate of 15%; one died from an aggressive brain cancer diagnosed shorty after t2; one was managed in another center after t1; one postponed the surgery after t1 until after the study, and the last one dropped out after t2 for unclear reasons). Nevertheless, the quantitative analysis of the results for the main outcome was statistically significant, and in the qualitative analysis saturation was reached with the available responses. The acceptance rate was high (60%), and participants who completed the study showed strong motivation and engagement throughout. We did not find differences in the main outcome according to gender, type of surgical indication or educational level, but the study was not specifically designed or powered to detect such differences. Finally, patient access to the material was not monitored by the platform, and whether patients consulted the material again especially after surgery was not asked. Notwithstanding this limitation, the specific study design corresponded well to real-life practice, where patients are given access to resources and are free to consult them as they wish. In conclusion, the present comprehensive assessment showed that the Medtronic Butterfly platform is a high-quality and useful educational resource for patients with surgical thyroid disease. The results support its broader dissemination and clinical use by HCPs, patient associations and individual patients, to facilitate patient engagement, higher satisfaction, and a more positive patient experience. Minor improvements would be welcome, including a summary and better online navigation; visualization on larger screens should be recommended to patient-users. Finally, healthcare providers should be cognizant of the high stress that patients retain even after surgery, an aspect that is not addressed specifically by the platform. Declarations ETHICS AND CONSENT TO PARTICIPATE The study was performed in accordance with the Declaration of Helsinki; it was approved by the Cantonal Commission on Ethics in Human Research of Vaud (Swiss Business Administration System for Ethics Committees identification number 2022-00395), and all patients provided written informed consent. FUNDING This work was funded by the Medtronic, Inc. External Research Program (ERP-2019-12080) to G.P.S. The funding support contributed to the salary of a doctoral student (M.-P. M.). Medtronic, Inc. had no influence on the implementation of the project or the drafting of the manuscript. Medtronic, Inc. reviewed and approved the final manuscript. ACKNOWLEDGEMENTS We would like to thank Marion Ribeyrol, Sunita Paul and Karen McKenzie from Medtronic, Inc. for access to the Butterfly platform and support with managing the grant. CONFLICT OF INTEREST G.S. received honoraria from Medronic, Inc. for serving on a panel of experts participating in the creation of the patient information platform that was later evaluated in this study. The other authors have no conflicts of interest to report. AUTHOR CONTRIBUTIONS G.S. conceived the project, secured funding and supervised the project. M. M. recruited and interviewed patients. M.M., G.R., I.G., D.C. and A.A. collected data. M.M., G.R. and G.S. analyzed data and prepared the figures and tables. M.M. and G.S. drafted the manuscript. All authors reviewed and edited the manuscript. SUPPLEMENTARY TABLE 1 English translation of the custom Debriefing Questionnaire. References Grigoriadis G, Koufakis T, Kotsa K. 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Rooney MK, et al. Readability of Patient Education Materials From High-Impact Medical Journals: A 20-Year Analysis. J Patient Exp. 2021;8:2374373521998847. Friedman DB, Hoffman-Goetz L. A systematic review of readability and comprehension instruments used for print and web-based cancer information. Health Educ Behav. 2006;33(3):352–73. Sand-Jecklin K. The impact of medical terminology on readability of patient education materials. J Community Health Nurs. 2007;24(2):119–29. Additional Declarations Competing interest reported. G.S. received honoraria from Medtronic, Inc. for serving on a panel of experts participating in the creation of the patient information platform that was later evaluated in this study. Supplementary Files SupplementaryTable1.docx English translation of the custom Debriefing Questionnaire. Cite Share Download PDF Status: Published Journal Publication published 29 Apr, 2026 Read the published version in BMC Medical Informatics and Decision Making → Version 1 posted Editorial decision: Revision requested 23 Sep, 2025 Reviews received at journal 22 Sep, 2025 Reviews received at journal 30 Aug, 2025 Reviewers agreed at journal 10 Aug, 2025 Reviewers agreed at journal 08 Aug, 2025 Reviewers invited by journal 08 Aug, 2025 Editor assigned by journal 08 Aug, 2025 Submission checks completed at journal 08 Aug, 2025 First submitted to journal 06 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7309071","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":499039660,"identity":"e7b16125-d9ac-4a60-8e0a-e58f5d5c80ff","order_by":0,"name":"Maria Moschofidou","email":"","orcid":"","institution":"Lausanne University Hospital and University of Lausanne","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Moschofidou","suffix":""},{"id":499039663,"identity":"d040a36f-854b-42fe-b835-32205493810e","order_by":1,"name":"Grégoire Racine","email":"","orcid":"","institution":"Lausanne University Hospital and University of Lausanne","correspondingAuthor":false,"prefix":"","firstName":"Grégoire","middleName":"","lastName":"Racine","suffix":""},{"id":499039665,"identity":"5bdd43ae-a717-48c5-8f5e-01b03519a2ba","order_by":2,"name":"Ilaria Giordani","email":"","orcid":"","institution":"Lausanne University Hospital and University of Lausanne","correspondingAuthor":false,"prefix":"","firstName":"Ilaria","middleName":"","lastName":"Giordani","suffix":""},{"id":499039666,"identity":"f43a0ea0-c054-4bb6-98cc-53a6ef43f2ab","order_by":3,"name":"Dionysios V. 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Sykiotis","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYNACAwjF2ABksDEwH2AGcyWI1CLBxsCWQIQWBpgWsDoeA7xa5N17H378UbBNTr6B/ZnkjAKbOj7+Mx8/F7YdZuCf3YBVi+GZ48bSPAa3jQ0O8JhJbjBIk2CTyN0sPROoReLOAexaZqQxSDMY3E7cwMDDJvnA4DBQC+82Zt62NAYDiQTsWuY/Y/75A6hlPshhYC38Z57h1SIvwcYmAXRYYsMBBpDDgFoYctiAWmxwajHgSWOzBvvlMI+x5QyDNMk2iTSg787Z8EjcwGFL+zHmmz/+3JaTb29/eLPnjw2/fP/hh595yiTk+GfgsAUeKswMLCgRwYNVPciWBgSb+QMuVaNgFIyCUTCyAQAIHFMni6CFxgAAAABJRU5ErkJggg==","orcid":"","institution":"Lausanne University Hospital and University of Lausanne","correspondingAuthor":true,"prefix":"","firstName":"Gerasimos","middleName":"P.","lastName":"Sykiotis","suffix":""}],"badges":[],"createdAt":"2025-08-06 11:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7309071/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7309071/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12911-026-03526-w","type":"published","date":"2026-04-29T15:57:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89230150,"identity":"c5fd5ff5-1eae-437e-b2e6-e3944d28bfe4","added_by":"auto","created_at":"2025-08-17 14:12:46","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":305238,"visible":true,"origin":"","legend":"\u003cp\u003e(\u003cstrong\u003eA\u003c/strong\u003e) Usefulness Scale for Patient Information Material (USE) total scores before (t2) and after (t3) surgery. (\u003cstrong\u003eB\u003c/strong\u003e-\u003cstrong\u003eD\u003c/strong\u003e) Respective subscales’ scores. The violin plots show individual patient data and indicate their respective medians and quartiles.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7309071/v1/0d2e2f9decabd0525e26270a.jpg"},{"id":89230157,"identity":"5d35581b-b298-4d02-9614-7172cdb43158","added_by":"auto","created_at":"2025-08-17 14:12:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":500987,"visible":true,"origin":"","legend":"\u003cp\u003e(\u003cstrong\u003eA\u003c/strong\u003e) e-Health Impact Questionnaire (eHIQ) total scores before (t2) and after (t3) surgery. (\u003cstrong\u003eB-D\u003c/strong\u003e) Respective scores of eHIQ-Part1 and its two subscales. (\u003cstrong\u003eE-H\u003c/strong\u003e) Respective scores of eHIQ-Part2 and its three subscales. The violin plots show individual patient data and indicate their respective medians and quartiles.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7309071/v1/11f244f7d1556e5dc7bc6a6c.jpg"},{"id":89231631,"identity":"119eace6-b555-4be8-9e30-f56b2bef97d5","added_by":"auto","created_at":"2025-08-17 14:20:47","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":405852,"visible":true,"origin":"","legend":"\u003cp\u003eScores for USE and eHIQ-Part2 before (t2) and after (t3) surgery according to (\u003cstrong\u003eA\u003c/strong\u003e) gender (male vs. female), (\u003cstrong\u003eB\u003c/strong\u003e) type of surgical indication (benign vs. oncological), and (\u003cstrong\u003eC\u003c/strong\u003e) education level (\u0026lt;9\u003csup\u003eth\u003c/sup\u003e grade vs. ≥9\u003csup\u003eth\u003c/sup\u003e grade). The violin plots show individual patient data and indicate their respective medians and quartiles.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7309071/v1/a32264055605d024f83e055d.jpg"},{"id":89231632,"identity":"2c2127c5-6452-429f-a74e-c20b950b5a75","added_by":"auto","created_at":"2025-08-17 14:20:47","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":292136,"visible":true,"origin":"","legend":"\u003cp\u003eScores for (\u003cstrong\u003eA\u003c/strong\u003e) Generalized Anxiety Disorder-7 (GAD-7), (\u003cstrong\u003eB\u003c/strong\u003e) Patient Health Questionnaire-9 (PHQ-9) and (\u003cstrong\u003eC\u003c/strong\u003e) Perceived Stress Scale-14 (PSS-14) before (t2) and after (t3) surgery. The violin plots show individual patient data and indicate their respective medians and quartiles.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7309071/v1/71d9e954cac34ff31cc95191.jpg"},{"id":89231637,"identity":"bee3c5b7-897f-4879-8d45-5e676fae9ddd","added_by":"auto","created_at":"2025-08-17 14:20:47","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":303085,"visible":true,"origin":"","legend":"\u003cp\u003eIndividual patient responses and scores for the 6-question questionnaire Brief DISCERN, assessing the quality of the material’s content. “Yes” responses, awarded 5 points each, are shown in gray, and “no” responses, awarded 0 points each, are shown in black. Total scores are shown as a heatmap with values ranging from 0 to 30.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7309071/v1/918356f9571685d0a4c94777.jpg"},{"id":89230163,"identity":"a988883d-a90d-4a89-aace-49d4e6203c20","added_by":"auto","created_at":"2025-08-17 14:12:47","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":505739,"visible":true,"origin":"","legend":"\u003cp\u003eIndividual investigator responses for Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-A/V). To save space, the wording of some questions has been abbreviated, taking care to preserve their original meaning. The assessment itself was conducted using the original, validated PEMAT-A/V with the full wording of each question. “Yes” responses, awarded 1 point each, are shown in gray, and “no” responses, awarded 0 points each, are shown in black.\u003c/p\u003e","description":"","filename":"Figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7309071/v1/74b24c334f7792d3f7cb571f.jpg"},{"id":108437626,"identity":"eb86c95c-2e20-4516-85a7-d8c24e38ec49","added_by":"auto","created_at":"2026-05-04 16:00:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2822252,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7309071/v1/67fea45e-937a-4f33-89f2-cddd24cfd762.pdf"},{"id":89230151,"identity":"a5c3471e-b638-4e67-b274-fa00bbc57435","added_by":"auto","created_at":"2025-08-17 14:12:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20556,"visible":true,"origin":"","legend":"\u003cp\u003eEnglish translation of the custom Debriefing Questionnaire.\u003c/p\u003e","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7309071/v1/108000a5456a26c01aaa078a.docx"}],"financialInterests":"Competing interest reported. G.S. received honoraria from Medtronic, Inc. for serving on a panel of experts participating in the creation of the patient information platform that was later evaluated in this study.","formattedTitle":"Comprehensive evaluation of Medtronic’s Butterfly platform, a new audiovisual information material for patient education and shared decision-making in surgical thyroid disease","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThyroid diseases alter the anatomy and/or impair the functionality of the thyroid gland, leading to detrimental effects on patient health and health-related quality of life (HRQoL). Their prevalence among adults in Westerns societies is around 6.6% [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and it is higher among women and older individuals. Despite efficient diagnostic tools and treatments and a generally favorable prognosis, thyroid dysfunction adversely impacts HRQoL even in benign thyroid disorders [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Similarly, despite an excellent overall prognosis in the majority of cases, thyroid cancer survivors also experience a reduction in their HRQoL [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Surgery is a critical moment in the trajectory of many patients with benign or malignant thyroid disease, because patient experience, surgical complications and other outcomes can have a major impact on HRQoL [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Thyroid surgery may be indicated for patients with thyroid cancer, large nodules that cause symptoms, nodules with a malignant, suspicious or indeterminate cytology [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], or conditions that cause hyperthyroidism [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Patient education is crucial in the decision-making of patients undergoing thyroid surgery to help them understand the procedure and its associated risks and benefits, potential alternatives to surgery, technical means to minimize complications, priorities in postoperative care, etc. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This is consistent with studies in other medical fields showing that effective educational interventions can foster cooperation and improve postoperative outcomes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In general, well-informed patients tend to experience less anxiety and more satisfaction with care, and they adhere better to postoperative instructions [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe use of information technology (IT) platforms to enhance patient engagement and provide accessible health information addressing the knowledge needs of patients and their families is a recognized application of medical informatics. Online patient information materials are highly relevant to shared decision-making in healthcare, and studies indicate that approximately 70% of patients prefer accessing health information online, highlighting the need for effective digital resources [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. By improving understanding of risks, benefits, and possible consequences of different choices, online patient information materials support more informed and personalized decisions [\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. They thus facilitate communication and empower patients to participate more actively and confidently in discussions with their healthcare providers (HCPs), and to articulate their preferences, values, and concerns. In these ways, online patient information materials help to shift the care model from physician-dominated to collaborative and patient-centered [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Challenges associated with such materials include their variable quality, reliability and accuracy, that may sometimes lead to misinformation or misunderstanding, as well as potential deviations from the information provided by HCPs that can lead to confusion or conflict [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese general principles and concerns also apply to the online information on thyroid diseases. Such information is often incomplete, particularly on critical topics such as diagnosis and treatment [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. For example, a study evaluating online information for the treatment of low-risk thyroid cancer indicated that most websites failed to incorporate updates from the 2015 American Thyroid Association (ATA) guidelines, and they often lacked essential details about treatment options necessary for informed decision-making [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Further, a review by the National Institute for Heath and Care Excellence (NICE) found high-quality evidence from 3 studies highlighting patients\u0026rsquo; need for further information, and emphasized that the lack of sufficient verbal information provided by health professionals may lead patients to potential online misinformation [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A study assessing patient information on thyroid cancer concluded that the quality of the respective websites is highly variable, with a predominance of low-quality content, highlighting the need for improved visibility of trustworthy sources and enhanced e-health literacy among patients [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These findings are consistent with a study that identified the information provided as an area for improvement even among thyroid cancer patients who were generally satisfied [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Indeed, an analysis of unmet information needs among thyroid cancer survivors showed that a significant proportion reported insufficient understanding before treatment [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Such findings indicate that, even though online resources cannot replace the information provided orally by HCPs, their quality, content and accessibility are essential to support informed decision-making and improve health outcomes. The present study performed a comprehensive evaluation of the Medtronic Butterfly platform, a new e-learning tool for patients undergoing thyroid surgery. The results indicate that patients perceived the material to be beneficial, with positive effects on their knowledge and ability to take action, including their participation in shared decision-making.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eThe Medtronic Butterfly platform\u003c/h2\u003e\u003cp\u003eThe Medtronic Butterfly platform is an innovative e-learning tool designed to enhance education for patients undergoing thyroid surgery. The platform was developed in collaboration with a multidisciplinary group of surgeons, endocrinologists, and patient advocacy organizations. Its goal is to improve patients\u0026rsquo; understanding of their thyroid conditions and the procedures they may undergo by offering (i) learning modules on thyroid conditions and treatments; (ii) step-by-step guides to surgical procedures and recovery expectations; (iii) insights into thyroid surgery; and (iv) post-surgery advice on managing recovery and adjusting to life after thyroid surgery. The co-construction process will be described in detail elsewhere. The platform is freely accessible online in English [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]; the French version is in the process of being made available.\u003c/p\u003e\u003cp\u003eThe platform's main menu comprises five sections with written information: \u0026ldquo;Understanding your condition, diagnosis and treatment options\u0026rdquo;; \u0026ldquo;Getting ready for your hospitalization\u0026rdquo;; \u0026ldquo;Understanding your hospitalization and surgery\u0026rdquo;; \u0026ldquo;Next steps and advice for the recovery period\u0026rdquo;; and \u0026ldquo;Post-surgical treatments\u0026rdquo;. Additionally, the platform features five educational videos: \u0026ldquo;What is the thyroid?\u0026rdquo;; \u0026ldquo;Diagnostic process\u0026rdquo;, \u0026ldquo;Understand the surgery; Thyroid Surgery\u0026rdquo;; \u0026ldquo;Understand your hospitalization\u0026rdquo;; \u0026ldquo;Taking care of your scar\u0026rdquo;. To complement this information, three downloadable leaflets provide practical guidance: \u0026ldquo;What to pack for my hospital stay\u0026rdquo;; \u0026ldquo;Pre-admission checklists\u0026rdquo;; and \u0026ldquo;Recommendations for recovery\u0026rdquo;. This structure provides a comprehensive overview for patients, ensuring they are well-informed about their condition, the surgical process, and the post-operative care.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy objectives, outcome measures, instruments, and schedule of assessments\u003c/h3\u003e\n\u003cp\u003eThe main objective of this single-arm cohort study was to perform a comprehensive evaluation of Medtronic\u0026rsquo;s Butterfly platform. The outcome measures, instruments, and schedule of assessments are indicated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The main primary outcome measures were the material\u0026rsquo;s impact on patients undergoing thyroid surgery and its usefulness for these patients; further primary outcome measures were the material\u0026rsquo;s quality, content, readability, understandability and actionability. Secondary outcome measures were the patients\u0026rsquo; levels of stress, anxiety and depression, and their potential correlation with the material\u0026rsquo;s impact and usefulness. The instruments used had been previously validated, except for the custom debriefing questionnaire used to assess the content; this was based on items developed from a literature review, and it was pilot tested with the first 5 study patients. For the eHIQ instrument, we produced a cross-culturally validated French translation in strict adherence with the methodology recommended by Oxford University; the French version is now officially available for use by others [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOutcome measures, instruments and schedule of assessments.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eQuestionnaires\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEvaluators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e\u003cp\u003eTime points\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003et0\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003et1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003et2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003et3\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUSE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUsefulness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ee-HIQ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImpact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGAD-7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePHQ-9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePSS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBrief DISCERN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQuality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDebriefing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCRF-t1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSociodemographic and clinical data\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInvestigators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCRF-t2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInvestigators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCRF-t3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInvestigators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFKGL, GFI, SMOG, FRES, Scolarius\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReadability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInvestigators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePEMAT-A/V\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnderstandability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInvestigators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePEMAT-A/V\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eActionability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInvestigators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLIWC-22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLinguistic Analysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInvestigators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYesChat Tone Analyzer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTone Style Analysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInvestigators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003et0: study enrolment; t1: before accessing the materials, 0\u0026ndash;2 weeks after t0; t2: 0\u0026ndash;2 weeks before surgery; t3: 2\u0026ndash;4 weeks after surgery; USE: Usefulness Scale for Patient Information Material; eHIQ: e-Health Impact Questionnaire; GAD-7: Generalized Anxiety Disorder-7; PHQ-9: Patient Health Questionnaire-9; PSS: Perceived Stress Scale; CRF: case report form; FKGL: Flesch-Kincaid Grade Level; GFI: Gunning Fog Index; SMOG: Simple Measure of Gobbledygook; FRES: Flesch Reading Ease Score; PEMAT-A/V: Patient Education Materials Assessment Tool for Audiovisual Materials; LIWC-22: Linguistic Inquiry and Word Count.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe material\u0026rsquo;s readability, understandability and actionability were assessed by the investigators using validated tools, without involving patient participation. Sociodemographic and clinical data were collected at study enrolment (t0), and other parameters were assessed by patient-users before accessing the material (t1, 0\u0026ndash;2 weeks after t0), after accessing the material but prior to surgery (t2, 0\u0026ndash;2 weeks before surgery), and post-surgery (t3, 2\u0026ndash;4 weeks after surgery). The duration between t1 and surgery varied, with a minimum interval of two weeks. At t1, patients completed 3\u0026ndash;7 questionnaires in person, with assistance from a doctoral student if necessary, and was then given access to the information material via a hyperlink. At t2 and t3, questionnaires were mailed to participants, who returned them using pre-paid envelopes.\u003c/p\u003e\n\u003ch3\u003eStudy participants and sample size calculation\u003c/h3\u003e\n\u003cp\u003eEligible patients were adults who could understand and complete questionnaires in French, were able to use online resources via a computer, tablet or cell phone, and had an indication for thyroid surgery for either benign thyroid disease (Graves\u0026rsquo; disease or benign nodules/goiter) or for suspected (indeterminate or suspicious cytology) or confirmed thyroid cancer. Patients were excluded if they were unable to follow procedures or provide consent or had had prior thyroid surgery. Patients were recruited at Lausanne University Hospital by proposing the study to all eligible patients between May 2022 and May 2023. The study was performed in accordance with the Declaration of Helsinki; it was approved by the Cantonal Commission on Ethics in Human Research of Vaud (Swiss Business Administration System for Ethics Committees identification number 2022\u0026thinsp;\u0026minus;\u0026thinsp;00395), and all patients provided written informed consent.\u003c/p\u003e\u003cp\u003eThe target sample size was calculated for the main primary outcome of impact, hypothesizing a mean score of at least 5 points (medium effect size) above the 65-point threshold for good impact in Part 2 of the eHIQ questionnaire [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. For a one-sample t-test, two-tailed significance p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and statistical power of 80%, G*Power [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] calculates a sample size of 27 patients, yielding an actual power of 83.6%.\u003c/p\u003e\n\u003ch3\u003eData handling and statistics\u003c/h3\u003e\n\u003cp\u003eData management was conducted using REDcap 14.0.12, and quantitative analyses were performed with GraphPad Prism 9.5.1 (GraphPad, San Diego, CA). For the main primary outcomes (eHIQ and USE scores), data were analyzed using one-sample t-test. For comparison of outcomes at different timepoints, data were analyzed using paired t-test (two timepoints; eHIQ and USE scores) or one-way repeated measures non-parametric ANOVA (three timepoints; GAD-7, PHQ-9 and PSS-14 scores). For comparisons between different patient groups, data were analyzed using paired t-test. For simplicity of presentation, data (e-HIQ) were rounded to the nearest integer. Data on the material\u0026rsquo;s content (debriefing questionnaire) were analyzed qualitatively using Clarke and Braun's six-step process for thematic analysis [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Data triangulation was achieved through the integration of quantitative and qualitative data, including also linguistic aspects (LIWC-22, quantitative) and tone style (YesChat Tone Analyzer, generative artificial intelligence).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePatient cohort\u003c/h2\u003e\u003cp\u003eA total of 54 potential participants were initially contacted; after screening, 48 met the enrolment criteria, among whom 28 agreed to participate (58% acceptance rate). Two were excluded at t0 due to changes in their treatment plan; of the 26 participants, 22 completed the study (there were 2 dropouts before t2 and two before t3; 15% total dropout rate). The mean and median age of participants was 50 and 49 years, respectively (standard deviation 14.76, range 20\u0026ndash;75); and 17 (65%) were female. Operations planned were total thyroidectomy (n\u0026thinsp;=\u0026thinsp;12, 46%) and lobo-isthmectomy (n\u0026thinsp;=\u0026thinsp;14, 54%). All types of surgical indications were represented: Graves\u0026rsquo; disease (n\u0026thinsp;=\u0026thinsp;3, 12%), benign thyroid nodule (n\u0026thinsp;=\u0026thinsp;7, 27%), thyroid nodule with cytology results that were indeterminate (Bethesda III or IV) or suspicious for malignancy (Bethesda V) (n\u0026thinsp;=\u0026thinsp;11, 42%), and thyroid cancer (n\u0026thinsp;=\u0026thinsp;5, 19%). Nearly half (n\u0026thinsp;=\u0026thinsp;12, 46%) of the patients reported that the disease was detected due to symptoms; in 5 patients (19%), diagnosis was secondary to detection of a neck lump, and in 9 (35%) it was an incidental finding on imaging. Only 5 participants (19%) had an education level below USA grade 9.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eUsefulness\u003c/h3\u003e\n\u003cp\u003eThe Usefulness Scale for Patient Information Material (USE) instrument, employed to assess the written part of the audiovisual information material (i.e., the webpages, forms and memos, excluding the videos), comprises three subscales (cognitive, emotional and behavioral), with 3 questions per subscale [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]; each question is scored from 0\u0026ndash;10, yielding a total score of 0\u0026ndash;90, with higher scores indicating higher perceived usefulness. Because there is no formal threshold for a highly useful material, we set a threshold of 60/90 points (67%, in analogy with the 65% threshold of the eHIQ instrument \u0026ndash; see below). Results are shown in \u003cb\u003eFig.\u0026nbsp;1\u003c/b\u003e. Among the patients who completed the questionnaire at t2 (n\u0026thinsp;=\u0026thinsp;24) and t3 (n\u0026thinsp;=\u0026thinsp;22), the mean total score for usefulness was 66\u0026thinsp;\u0026plusmn;\u0026thinsp;10 (range 53\u0026ndash;85) at t2 and 66\u0026thinsp;\u0026plusmn;\u0026thinsp;15 (range 20\u0026ndash;86) at t3 (Fig.\u0026nbsp;1A); despite variable trends for individual patients, there was no significant difference in total scores between t2 and t3. The single outlier who indicated the lowest scores across all subscales at t3 explained that the information provided did not match well her lived experience. These results indicate that a one-time assessment of the material would have been sufficient overall, probably before surgery (t2), when patients are most likely to consult the material in clinical practice. This is consistent with the observation that the mean usefulness scores were significantly above the threshold at t2 (one-sample t-test, p\u0026thinsp;=\u0026thinsp;0.0087) but not at t3 (p\u0026thinsp;=\u0026thinsp;0.1078), noting again the single outlier. Nevertheless, at both t2 and t3, most patients gave scores above the threshold: 15/24 (63%) at t2 and 16/22 (73%) at t3. Patterns in the three subscales were like the total scores (Fig.\u0026nbsp;1B-D). Most patients scored in the upper half of the range, and there were no significant differences in scores between t2 and t3 in any of the subscales: cognitive, 24\u0026thinsp;\u0026plusmn;\u0026thinsp;4 (range, 17\u0026ndash;30) at t2 vs. 24\u0026thinsp;\u0026plusmn;\u0026thinsp;5 (range,14\u0026ndash;30) at t3; emotional, 21\u0026thinsp;\u0026plusmn;\u0026thinsp;4 (range, 12\u0026ndash;27) at t2 vs 20\u0026thinsp;\u0026plusmn;\u0026thinsp;6 (range, 2\u0026ndash;28) at t3; and behavioral, 21\u0026thinsp;\u0026plusmn;\u0026thinsp;4 (range, 15\u0026ndash;30) at t2 vs. 21\u0026thinsp;\u0026plusmn;\u0026thinsp;6 (range, 4\u0026ndash;30) at t3. Taken together, these findings indicate that the written part of the information material was useful for most patients before surgery, especially at the cognitive level, but also at the emotional and behavioral levels.\u003c/p\u003e\n\u003ch3\u003eImpact\u003c/h3\u003e\n\u003cp\u003eThe eHIQ instrument comprises two parts; the first one assesses patients\u0026rsquo; general attitudes toward using the internet to access health information, and the second assesses patients\u0026rsquo; attitudes towards the specific information material under study. The mean scores in Part 2 were 74\u0026thinsp;\u0026plusmn;\u0026thinsp;9 (range, 52\u0026ndash;91) before surgery and 69\u0026thinsp;\u0026plusmn;\u0026thinsp;10 (range, 50\u0026ndash;93) after surgery (Fig.\u0026nbsp;2E). The score at t2, but not at t3, was significantly above the threshold of 65/100 points (p\u0026thinsp;=\u0026thinsp;0.0087 and p\u0026thinsp;=\u0026thinsp;0.1078, respectively). The percentage of patients who gave scores\u0026thinsp;\u0026ge;\u0026thinsp;65 was 75% at t2 (18/24) and 73% at t3 (16/22). These results reflect positive attitudes towards the new information material among patients preparing for surgery. Even though there was a significant positive correlation of Part 2 scores before and after surgery (r\u0026thinsp;=\u0026thinsp;0.646, p\u0026thinsp;=\u0026thinsp;0.001), mean scores after surgery were significantly (albeit slightly) lower than before surgery (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001); this indicates that the overall perceived impact of the new information material is highest before surgery. Lastly, there was a positive correlation (r\u0026thinsp;=\u0026thinsp;0.43, p\u0026thinsp;=\u0026thinsp;0.035) between pre-surgery usability scores (USE at t2) and perceived impact of educational materials (eHIQ-Part 2 at t2), indicating that participants who rated the materials as more usable also reported good impact. This highlights that usability plays a role in enhancing the overall effectiveness of educational tools and provides confidence in the use of both instruments as orthogonal measures to assess the new material\u0026rsquo;s usefulness and impact.\u003c/p\u003e\u003cp\u003e We also explored whether the impact of the new information material (as reflected in the eHIQ-Part 2 score) varied according to patient characteristics (gender, type of surgical indication, and education level). No significant differences were found, acknowledging however the small size of some of the subgroups (Fig.\u0026nbsp;3).\u003c/p\u003e\u003cp\u003ePart 2 comprises three subscales: \u0026ldquo;confidence and identification\u0026rdquo; assesses the self- confidence of patients regarding the material; \u0026ldquo;information and presentation\u0026rdquo; assesses trust and suitability of the material; and \u0026ldquo;understanding and motivation\u0026rdquo; assesses self-efficacy to determine whether patients were motivated to take action based on the information presented. The respective mean scores before and after surgery were 68\u0026thinsp;\u0026plusmn;\u0026thinsp;10 (range 44\u0026ndash;92) vs. 64\u0026thinsp;\u0026plusmn;\u0026thinsp;10 (range, 44\u0026ndash;86), 80\u0026thinsp;\u0026plusmn;\u0026thinsp;10 (range 56\u0026ndash;97) vs. 72\u0026thinsp;\u0026plusmn;\u0026thinsp;12 (range, 50\u0026ndash;97), and 72\u0026thinsp;\u0026plusmn;\u0026thinsp;11 (range, 53\u0026ndash;97) vs. 70\u0026thinsp;\u0026plusmn;\u0026thinsp;11 (range, 50\u0026ndash;97) (Fig.\u0026nbsp;2F-H). The fact that the scores are highest for \u0026ldquo;information and presentation\u0026rdquo; is not surprising, because it is arguably easier to present information than to inspire trust or motivate action. Nevertheless, the findings indicate that the information material has a positive impact on all these aspects. Similarly, the results from USE showed a higher impact regarding the level of knowledge compared to the other subscales (Fig.\u0026nbsp;1B-D). Finally, the lower overall Part 2 scores at t3 compared at t2 (Fig.\u0026nbsp;2E) seem to be due to the significantly lower scores in the subscale \u0026ldquo;information and presentation\u0026rdquo; (p\u0026thinsp;=\u0026thinsp;0.0026) (Fig.\u0026nbsp;2G). This suggests that the perceived impact of the new information material decreases after surgery mainly because the perceived relevance of the procedure-related information is lower. The extent to which the information provided matched a particular patient\u0026rsquo;s actual lived experience may also play a role, at least for some patients.\u003c/p\u003e\u003cp\u003ePart 1 comprises two subscales: the first one assesses attitudes towards online health information in general, including factors such as readability, trust, and making decisions based on online information; and the second assesses attitudes towards sharing health experiences online. Before surgery, the mean score for the first subscale was significantly lower compared to the second one (52\u0026thinsp;\u0026plusmn;\u0026thinsp;14 vs. 59\u0026thinsp;\u0026plusmn;\u0026thinsp;15, p\u0026thinsp;=\u0026thinsp;0.024), with both being below the threshold of 65 points (Fig.\u0026nbsp;2C-D). These findings suggest that patients in the present study had a lower initial inclination towards using the internet for general health information and were somewhat hesitant to trust it, even though they were somewhat more open to sharing their health experiences online. After surgery, the scores for the first and second subscale were 57\u0026thinsp;\u0026plusmn;\u0026thinsp;18 and 62\u0026thinsp;\u0026plusmn;\u0026thinsp;13, respectively (Fig.\u0026nbsp;2C-D). There was thus a significant increase in general attitudes towards online health information (p\u0026thinsp;=\u0026thinsp;0.033), with no significant difference in inclination towards sharing experiences with others online. This indicates that use of the new material increases patients\u0026rsquo; trust on the internet as a source of health-related information, which is a very positive finding regarding the material\u0026rsquo;s impact. Conversely, the absence of an effect on inclination towards sharing experiences with others online is expected, because use of the material does not entail such interactions.\u003c/p\u003e\u003cp\u003eThere was a significant, moderate positive correlation between the scores in Part 1 and Part 2 at t2 (r\u0026thinsp;=\u0026thinsp;0.54, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). However, Part 2 scores were significantly higher than Part 1 scores at both t2 and t3 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001; \u003cb\u003eFig.\u0026nbsp;2B, 2E)\u003c/b\u003e. This indicates that the new material was appreciated by the participants, and that this positive impact was achieved despite the generally reserved initial (and later) attitudes towards using the internet for health information.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eAnxiety (GAD-7), depression (PHQ-9) and stress (PSS-14)\u003c/h2\u003e\u003cp\u003eAnxiety seems to vary substantially between participants. Among the patients who completed the study, the mean GAD-7 scores at the various time points were very similar: 5\u0026thinsp;\u0026plusmn;\u0026thinsp;6 at (t1), 5\u0026thinsp;\u0026plusmn;\u0026thinsp;5 at (t2), and 4\u0026thinsp;\u0026plusmn;\u0026thinsp;5 at (t3) (p\u0026thinsp;=\u0026thinsp;0.73) (Fig.\u0026nbsp;4A), with respectively 3, 2 and 4 patients scoring above the threshold of \u0026ge;\u0026thinsp;10 points that indicates at least moderate anxiety [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In some participants there seemed to be an upward trend after access to the material and a downward trend after surgery (Fig.\u0026nbsp;4A); this might be related to the fact that these participants completed their questionnaire very close to the day of surgery. Finally, one participant had a low level of anxiety before surgery that increased markedly after surgery (Fig.\u0026nbsp;4A); in the debriefing questionnaire she stated that she had not actually experienced what the information material described.\u003c/p\u003e\u003cp\u003ePHQ-9 scores also varied substantially between patients, with some showing extreme variations that are difficult to explain. With few exceptions, most patients did not appear to have symptoms of depression; mean scores were 7\u0026thinsp;\u0026plusmn;\u0026thinsp;6 at t1, 6\u0026thinsp;\u0026plusmn;\u0026thinsp;5 at t2, and 6\u0026thinsp;\u0026plusmn;\u0026thinsp;4 at t3 (Fig.\u0026nbsp;4B). A total of 5 patients at each time point had a score\u0026thinsp;\u0026ge;\u0026thinsp;10 indicating at least moderate depression [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Similar to GAD-7 scores, there were no significant differences in PHQ-9 scores over time.\u003c/p\u003e\u003cp\u003ePSS-14 results indicated moderate to high perceived stress levels among the patients throughout the study. Mean scores were 32\u0026thinsp;\u0026plusmn;\u0026thinsp;6 at t1, 30\u0026thinsp;\u0026plusmn;\u0026thinsp;7 at t2, and 30\u0026thinsp;\u0026plusmn;\u0026thinsp;5 at t3 (Fig.\u0026nbsp;4C). Across the time points, all scores but one (at t2) were \u0026ge;\u0026thinsp;19, indicating at least moderate levels of perceived stress, and a total of 2 patients at each time point had a score\u0026thinsp;\u0026ge;\u0026thinsp;38 indicating high stress [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Similar to GAD-7 and PHQ-9 scores, there were no significant differences in PSS-14 scores over time.\u003c/p\u003e\u003cp\u003eCorrelations were examined between these three psychological measures at t1 and the two impact measures (USE and eHIQ-Part 2 scores) at t3. A significant positive correlation was observed between GAD-7 and eHIQ-Part 2 scores (r\u0026thinsp;=\u0026thinsp;0.457, p\u0026thinsp;=\u0026thinsp;0.032), suggesting that the material has more impact on patients with higher basal anxiety levels. Further, a significant negative correlation was observed between PHQ-9 and USE scores (r=-0.504, p\u0026thinsp;=\u0026thinsp;0.010), suggesting that the perceived usefulness of the material is lower among patients with higher basal depression levels.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eQuality (Brief DISCERN)\u003c/h2\u003e\u003cp\u003eThe Brief DISCERN is a simple, six-question tool designed to help patients and consumers quickly assess the quality of health information on the web, especially regarding treatment choices [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Among the 22 patients, 21 completed the instrument at the end of the study (t3). The majority (19/21, 90%) gave scores\u0026thinsp;\u0026gt;\u0026thinsp;16, with 14/21 (67%) giving a maximum score of 30; the mean score was 25\u0026thinsp;\u0026plusmn;\u0026thinsp;8 (Fig.\u0026nbsp;5). These data indicate a very good content quality of the new audiovisual material [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The main reason for lower scores is primarily due to the second question, which assesses the clarity of publication dates and identifiable sources. In this regard, 7 patients correctly pointed out that the publication dates were not mentioned.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eContent (custom debriefing questionnaire)\u003c/h2\u003e\u003cp\u003eThe Debriefing Questionnaire provides comprehensive feedback through closed-ended (e.g., Likert scale, yes/no) and open-ended questions, assessing clarity, usefulness, satisfaction, and difficulties, while also inviting suggestions or additional comments (\u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e). The vast majority of patients (87%) indicated that they found the material useful or very useful, and none found it not at all useful. At the emotional level, patients reported that the material made them feel calm, relieved, confident, reflective and curious. All patients indicated trust in the source of the material and believed that the information provided is accurate and reliable. Their main topics of interest were thyroid function, what is going to happen, preparation for hospitalization, and the post-hospitalization period. Except for two patients, the information provided reportedly corresponded to what actually happened. No information was identified as upsetting or difficult to understand.\u003c/p\u003e\u003cp\u003ePatients found the material useful because it was (i) clear and concise (e.g., \u0026ldquo;the content is good for informing about the disease\u0026rdquo;); (ii) relevant and applicable (e.g., \u0026ldquo;explanations of my case\u0026rdquo;); (iii) accessible (e.g., \u0026ldquo;the format is perfect\u0026rdquo;); and (iv) empowering (e.g., \u0026ldquo;useful to know the logical sequence of events to better prepare me\u0026rdquo;). On the other hand, some patients indicated aspects that could be improved: (i) limited scope, not comprehensive enough to address all possible health concerns or conditions that patients may have (e.g., \u0026ldquo;I was in stress to find information on exophthalmos, and I was disappointed not to find any\u0026rdquo;, \u0026ldquo;I would have liked to see more examples of recommended foods\u0026rdquo;); (ii) technical difficulties (e.g., \u0026ldquo;It's hard to read on a cell phone. I had to use a tablet. The font size is very small\u0026rdquo;, \u0026ldquo;The structure is well done but I sometimes got lost to find a page that I wanted to review\u0026rdquo;); (iii) language and cultural barriers (e.g., \u0026ldquo;My suggestion is to subtitle the videos so that non-French speaking patients can understand better. Then the text can be summarized\"; (iv) contradictions with their lived experience (e.g., \u0026ldquo;At the hospital I was advised to take the calcium 2 hours after the thyroid hormone and on the site, it is a 4-hour delay\u0026rdquo;, \u0026ldquo;I feel little scared because the doctor had not explained all the details to me\u0026rdquo;). Overall, the most common comments for improvement concerned requests for subtitles, improved navigation, and additional nutritional advice.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eReadability\u003c/h2\u003e\u003cp\u003eThe complexity of the written text was evaluated for each section using four established readability formulas [Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG), and Gunning Fog Index (GFI)], and the corresponding grade and reading level were calculated [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. For the French version, the French-specific tool Scolarius was also employed [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. As recommended for readability analyses, texts were pre-formatted for analysis in a standardized manner, including removal of bullet points and headings [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The results (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) show that both language versions are written at a higher complexity than the generally recommended 6th -8th grade level [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], with only one (French version) or two (English version) sections meeting recommendations. Most sections (14/18) showed higher complexity in the French version compared to the English one (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); this is consistent with what has been observed for other patient information materials [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], and it may be related to the differences in language structure and/or their treatment by the readability formulas [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. An extreme difficulty indicated by Scolarius for section \u0026ldquo;12. Pre-admission check list\u0026rdquo; is likely skewed due to its check-list format, considering that it is scored as standard by the other tools. Despite the higher complexity of the texts compared to recommendations for patient-oriented materials, neither the quantitative nor the qualitative feedback of patients highlighted challenges with the material\u0026rsquo;s readability; for example, even though most participants\u0026rsquo; (21/26, 80.77%) educational level was above the 8th grade, all participants agreed or fully agreed that \u0026ldquo;the language used by the website made it easy to understand\u0026rdquo; (eHIQ-Part 2 question 6).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReadability analysis results per section of the English and French versions.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"15\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eEnglish version\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"8\" nameend=\"c15\" namest=\"c8\"\u003e\u003cp\u003eFrench version\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSection\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFKGL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGFI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSMOG\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFRES\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGrade\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eReading level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFKGL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eGFI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eSMOG\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eFRES\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003eGrade\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c13\"\u003e\u003cp\u003eReading level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e\u003cp\u003eScolarius\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Understand my condition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e56.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003esomewhat difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e14.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e40.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003edifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003ecollege\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Understanding the diagnostic process\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e57.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e33.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003edifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e139\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003ecollege\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Understand the treatment options\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e11.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003edifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003ecollege\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Questions to ask to your surgeon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e9.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e61.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e7th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003eaverage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003eprimary\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Understand the surgery - The thyroid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e50.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e14.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e14.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e36.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003ecollege entry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003every difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003ecollege\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. What will happen before your surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e50.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e16.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e15.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e28.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003edifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e153\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003euniversity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. Medication advices\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ecollege\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eprofessional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e16.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e18.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e16.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e15.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003ecollege entry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003every difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003ecollege\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. Understand my hospitalization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e36.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003esomewhat difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e38.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003esecondary\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9. What are the next steps after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e46.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003edifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e13.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e15.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e32.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003edifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003ecollege\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10. What to pack for my hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e52.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003edifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e11.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e38.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e168\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003euniversity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11. How to manage anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e67.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eaverage - slightly dif.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e11.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e13.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e42.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e10th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003esomewhat dif.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e174\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003euniversity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12. Pre-admission check list\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eaverage - slightly dif.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e11.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e13.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e42.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e10th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003esomewhat dif.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e329\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003einitiated\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13. Managing pain after your surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e56.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e16.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e15.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e33.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003ecollege entry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003every difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e159\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003euniversity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14. Instruction for scar care after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003esomewhat difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e13.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e16.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e15.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e34.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003edifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003ecollege\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15. Managing your weight after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e58.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e14.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e39.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003edifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003esecondary\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16. Recovery period recommendations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e61.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eslightly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e14.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e36.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003esecondary\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17. Hormone treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e56.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003esomewhat difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e13.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e35.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e11th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003efairly difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003euniversity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18. Radioactive iodine treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e47.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003edifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e13.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e15.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e14.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e30.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003ecollege entry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003every difficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e134\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003ecollege\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"15\"\u003eThe Flesch-Kincaid Grade Level (FKGL) indicates the U.S. grade level needed to understand the text, with lower scores indicating easier readability; the Gunning Fog Index (GFI) estimates the years of formal education needed to understand the text on first reading, with lower scores indicate easier readability; the Simple Measure of Gobbledygook (SMOG) estimates the years of education needed to understand a piece of writing, with lower scores indicating easier readability; the Flesch Reading Ease Score (FRES) scores text on a 100-point scale, with higher scores indicating easier readability; and Scolarius provides a comparison to other texts of the same type, with lower scores indicating easier readability.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eUnderstandability and actionability (PEMAT-A/V)\u003c/h2\u003e\u003cp\u003eThe Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-A/V) was used to evaluate the understandability (13 questions) and actionability (4 questions) of the educational material. Five investigators independently conducted the assessment, discussing and resolving uncertainties wherever relevant. Results showed a perfect actionability score of 100% and an understandability score of 82% that exceeded the 70% threshold, indicating a high-quality material (Fig.\u0026nbsp;6). The inter-rater reliability, measured by Fleiss Kappa, indicated fair agreement among the five reviewers (κ\u0026thinsp;=\u0026thinsp;0.39, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The material demonstrated strengths in understandability through well-structured information, effective visual aids, and use of everyday language; contextualization of the latter should consider that the investigators were HCPs. Areas where understandability could be improved were also identified: a summary was lacking; there was sometimes too much text on a single page, making it difficult to read; better use of illustrations could reduce text density; there were minor inconsistencies in terminology and occasional typographical errors; topic separation could be improved and section transitions could be clearer; and some anatomy- and insurance-related terms should be culturally adapted (for a Swiss audience). These findings suggest that while the material is largely comprehensible and perfectly actionable, targeted refinements could further enhance its understandability.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLinguistic analysis and tone style analysis\u003c/h2\u003e\u003cp\u003e The Linguistic Inquiry and Word Count is a validated scientific tool specifically designed for text analysis, used to extract linguistic, psychological, and social insights from written or spoken text. To analyze the English and French versions of the material, we used the latest version (LIWC-22) and its respective dictionaries [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe French text was longer than the English one (15.457 words vs. 14.612, respectively), despite an identical number of words per sentence (n\u0026thinsp;=\u0026thinsp;22). It also had a higher percentage of \u0026ldquo;big words\u0026rdquo; (32% vs. 25%, respectively); this refers to words with \u0026ge;\u0026thinsp;7 letters, which is a proxy for text complexity, reflecting the use of advanced vocabulary or formal language. LIWC-22 could calculate percentages for psychological or linguistic dimensions (LIWC Summary Measures) only for the English version; besides, the percentage of text words present in the respective dictionaries were 87% for the English text and only 73% for the French one, indicating that the former aligns better with LIWC's analytical framework. Results for the specific LIWC Summary Measures, expressed as percentiles, were as follows: (i) Analytical thinking: 57, indicating an intermediate degree between a hierarchical and structured communication and a more narrative, intuitive, and informal style. (ii) Clout: 84, indicating a confident, authoritative, and leadership-oriented communication style in which the writer feels secure in their knowledge. (iii) Authenticity: 36, indicating a text that is more socially cautious, formal, or pre-prepared. (iv) Emotional tone: 32, suggesting a more negative or downbeat sentiment, marked by frequent use of negative emotion words. Indeed, the percentages of emotion-positive and emotion-negative words in the English version were 0.23% and 0.64% respectively. Interestingly, in the French version, the respective percentages were 2.41% and 2.13%; this discrepancy likely reflects linguistic and cultural differences in expression.\u003c/p\u003e\u003cp\u003eFinally, to obtain a more comprehensive and qualitative analysis of the material\u0026rsquo;s tone and style, the English and French versions were analyzed using YesChat Tone Analyzer [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. The results (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) show that the content effectively maintains a neutral and informative tone, using clear language to educate readers about thyroid function and related medical-surgical procedures. In both versions, the tone, style, voice and linguistic patterns are suitable for patient education, balancing professionalism, empathy and accessibility to inform without causing alarm or confusion. Some distinct tonal and grammatical differences emerged, with the English version being more direct and conversational, creating a friendly and personal atmosphere to foster intimacy and reassurance. In contrast, the French version adopts a more formal and polite tone including passive constructions that result in a courteous but detached tone, emphasizing respect and education over emotional engagement. Ultimately, both versions engage the reader, but the English text establishes a warmer connection, while the French text maintains formality and respect, which also likely relates to linguistic and cultural differences.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResults of the tone style analysis of the text in the English and French versions.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnglish version\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrench version\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTone\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCalm, reassuring and educational. Blends clinical accuracy with empathetic clarity.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReassuring, instructive and compassionate. The text anticipates patient anxiety and responds with warmth and clarity.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStyle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFormal yet accessible; uses structured headings, bullet points, and short paragraphs for readability.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComprehensive and didactic, broken into structured headings and subheadings for ease of navigation. Uses bullet points, analogies and diagrams or placeholders to support explanation.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVoice\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNeutral, informative, and professional. Consistently uses second person (\u0026ldquo;you\u0026rdquo;) to engage readers and personalize complex medical explanations.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmpathetic and authoritative. Speaks directly to the reader (\u0026ldquo;you\u0026rdquo;) in a professional yet human-centered manner.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLinguistic patterns\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDefinitions followed by examples or analogies; use of parenthetical clarification (e.g., \"also known as T3\"). Emphasis on demystifying technical terms. Gentle encouragement to ask questions, reduce anxiety, and participate in care. Softened clinical language (e.g., \u0026ldquo;not too painful,\u0026rdquo; \u0026ldquo;mild hoarseness\u0026rdquo;) to reduce fear.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequent use of parenthetical definitions (e.g., \u0026ldquo;T3 \u0026ndash; triiodothyronine\u0026rdquo;). Mild repetition for reinforcement. Soothing language when referring to sensitive topics (e.g., cancer, surgery, biopsy). Present tense and active voice to maintain immediacy and support understanding. Occasional rhetorical questions to engage the reader (e.g., \u0026ldquo;What is an endocrinologist?\u0026rdquo;). Step-by-step procedural outlines to reduce uncertainty and build trust.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present comprehensive assessment of the Medtronic Butterfly educational platform providing information to patients with surgical thyroid disease documented numerous strengths of the new material and identified some areas for improvement. The patients\u0026rsquo; feedback underscored the usefulness and positive impact of the material, particularly prior to surgery. Indeed, despite the low tendency of the participants to use the internet for general health information and their general hesitation to trust online resources, patient trust and suitability of the material were very highly scored. The patients assessed the written information as high-quality, an aspect known to play a pivotal role in its effectiveness. Assessment of the material\u0026rsquo;s understandability and actionability by the medical professionals showed that the content is not only very informative but also highly practicable, with a perfect actionability score. Qualitative analysis of patients\u0026rsquo; feedback confirmed that the material exhibits satisfactory clarity and comprehensibility. Importantly, in most cases, the information provided regarding surgery corresponded to what actually occurred. The absence of upsetting or difficult to understand information also contributed to the material\u0026rsquo;s effectiveness. Further, analysis of the text using informatics tools revealed a neutral and informative tone, with clear, balanced, accessible and empathetic language that is suitable to educate and reassure patients. Factors known to influence engagement with web-based healthcare information include comprehensibility, support, adaptability, accessibility, visual appeal, content quality, and credibility [\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e]; the platform\u0026rsquo;s performance was overall well-rated regarding such aspects. In general, young adults find the video format easy to learn from [\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e], and the platform\u0026rsquo;s videos were systematically viewed and well appreciated according to patient feedback. In addition to digital and health literacy, concerns about privacy represent barriers to the adoption of digital health technology [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e]; no such concerns were raised by the participants, which was reassuring.\u003c/p\u003e\n\u003cp\u003eAmong areas for potential improvement, the main one was the readability of the material, which was assessed as more advanced than the recommended level (6th -8th grade) [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e]. Accordingly, the material should ideally be written in even simpler language. However, readability formulas may not be optimal for patient education materials [\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e], such as names of active substances that were included in the present material. Indeed, patients\u0026apos; quantitative and qualitative feedback did not indicate any issues with the readability of the material. Rather, participants were mostly concerned with difficulties in webpage navigation in relation to the main menu structure, even though the overall usability remained satisfactory. The material was specifically reported as difficult to view on smartphones, particularly due to size limitations. Interestingly, even though all users consulted the web pages and videos, more than half indicated they did not utilize the available downloadable documents. While the margin to further adapt the material for smartphones may have its limits, optimizing navigation on tablets or computers should be readily feasible. Further improvements could be made to enhance understandability, e.g., include a summary and shorten some texts; cultural relevance could also be considered regarding notably insurance-related terms; and some patients indicated a desire for additional dietary advice. Finally, the results showed low levels of anxiety or depression but high levels of stress among participants, which persisted even after surgery. Even though the linguistic and tone analysis showed that the text was suitable to reassure patients, the material does not address explicitly high stress levels, and therefore physicians who recommend it to their patients should consider other resources for anxiety management, such as referral to a psychologist, if needed.\u003c/p\u003e\n\u003cp\u003eA key strength of this study is the use of multiple tools, both quantitative and qualitative, to evaluate various relevant aspects of the new educational material. In addition to achieving a comprehensive assessment, this also facilitated the cross-validation of the main findings; for example, the high understandability and actionability assessed by the investigators in PEMAT-A/V mirrored the high level of understanding and motivation indicated by the patients in eHIQ Part 2. Similarly, there was clear correspondence between patients\u0026rsquo; responses in USE, eHIQ Part 2 and the qualitative debriefing questionnaire, as well as between these three questionnaires and the automated results of the linguistic and tone analysis by informatics tools on respective aspects. These consistencies among the assessment results by patients (providing genuine insights and feedback about their experiences), researchers (maintaining scientific rigor in the methodology) and informatics tools (avoiding bias) strongly support the internal validity of the present evaluation, as does the overall stability of the vast majority of responses across the respective time points.\u003c/p\u003e\n\u003cp\u003eOne limitation of the study is the small sample size, with 22/26 patients completing the study (drop out-rate of 15%; one died from an aggressive brain cancer diagnosed shorty after t2; one was managed in another center after t1; one postponed the surgery after t1 until after the study, and the last one dropped out after t2 for unclear reasons). Nevertheless, the quantitative analysis of the results for the main outcome was statistically significant, and in the qualitative analysis saturation was reached with the available responses. The acceptance rate was high (60%), and participants who completed the study showed strong motivation and engagement throughout. We did not find differences in the main outcome according to gender, type of surgical indication or educational level, but the study was not specifically designed or powered to detect such differences. Finally, patient access to the material was not monitored by the platform, and whether patients consulted the material again especially after surgery was not asked. Notwithstanding this limitation, the specific study design corresponded well to real-life practice, where patients are given access to resources and are free to consult them as they wish.\u003c/p\u003e\n\u003cp\u003eIn conclusion, the present comprehensive assessment showed that the Medtronic Butterfly platform is a high-quality and useful educational resource for patients with surgical thyroid disease. The results support its broader dissemination and clinical use by HCPs, patient associations and individual patients, to facilitate patient engagement, higher satisfaction, and a more positive patient experience. Minor improvements would be welcome, including a summary and better online navigation; visualization on larger screens should be recommended to patient-users. Finally, healthcare providers should be cognizant of the high stress that patients retain even after surgery, an aspect that is not addressed specifically by the platform.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eETHICS AND CONSENT TO PARTICIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was performed in accordance with the Declaration of Helsinki; it was approved by the Cantonal Commission on Ethics in Human Research of Vaud (Swiss Business Administration System for Ethics Committees identification number 2022-00395), and all patients provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded by the Medtronic, Inc. External Research Program (ERP-2019-12080) to G.P.S. The funding support contributed to the salary of a doctoral student (M.-P. M.). Medtronic, Inc. had no influence on the implementation of the project or the drafting of the manuscript. Medtronic, Inc. reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Marion Ribeyrol, Sunita Paul and Karen McKenzie from Medtronic, Inc. for access to the Butterfly platform and support with managing the grant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eG.S. received honoraria from Medronic, Inc. for serving on a panel of experts participating in the creation of the patient information platform that was later evaluated in this study. The other authors have no conflicts of interest to report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eG.S. conceived the project, secured funding and supervised the project. M. M. recruited and interviewed patients. M.M., G.R., I.G., D.C. and A.A. collected data. M.M., G.R. and G.S. analyzed data and prepared the figures and tables. M.M. and G.S. drafted the manuscript. All authors reviewed and edited the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSUPPLEMENTARY TABLE 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnglish translation of the custom Debriefing Questionnaire.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGrigoriadis G, Koufakis T, Kotsa K. Epidemiological, Pathophysiological, and Clinical Considerations on the Interplay between Thyroid Disorders and Type 2 Diabetes Mellitus. Med (Kaunas), 2023. 59(11).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGarmendia Madariaga A, et al. The incidence and prevalence of thyroid dysfunction in Europe: a meta-analysis. 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J Educ Health Promot. 2022;11:402.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLim CA, Ingledew PA. Analysis of the quality of meningioma education resources available on the Internet. Neurooncol Pract. 2021;8(2):129\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFahy E, et al. Quality of patient health information on the Internet: reviewing a complex and evolving landscape. Australas Med J. 2014;7(1):24\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChang KL, Grubbs EG, Ingledew PA. An Anal Qual Thyroid Cancer Websites Endocr Pract. 2019;25(10):1003\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDoubleday AR, et al. Online Information for Treatment for Low-Risk Thyroid Cancer: Assessment of Timeliness, Content, Quality, and Readability. J Cancer Educ. 2021;36(4):850\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ein \u003cem\u003eInformation for people with thyroid disease: Thyroid disease: assessment and management: Evidence review A\u003c/em\u003e. 2019: London.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuenzel U, et al. Evaluation of the Quality of Online Information for Patients with Rare Cancers: Thyroid Cancer. J Cancer Educ. 2018;33(5):960\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiez JJ, Galofre JC. Thyroid cancer patients satisfaction at the management outcome: an analysis of the results of a nationwide survey in 485 subjects. BMC Health Serv Res. 2021;21(1):158.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKarcioglu AS, et al. Analysis of Unmet Information Needs Among Patients With Thyroid Cancer. JAMA Otolaryngol Head Neck Surg. 2023;149(2):110\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eMedtronic e-learning - English\u003c/em\u003e. 2022; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.medtronic.com/content/dam/medtronic-com/xd-en/impact/elearning/thyroid-content-solution/story.html\u003c/span\u003e\u003cspan address=\"https://www.medtronic.com/content/dam/medtronic-com/xd-en/impact/elearning/thyroid-content-solution/story.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eeHIQ. \u003cem\u003eAvailable languages\u003c/em\u003e. 2023; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://innovation.ox.ac.uk/wp-content/uploads/2014/09/eHIQ_language-list_April_2023.pdf\u003c/span\u003e\u003cspan address=\"https://innovation.ox.ac.uk/wp-content/uploads/2014/09/eHIQ_language-list_April_2023.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTalboom-Kamp E, et al. Patients' Attitudes Toward an Online Patient Portal for Communicating Laboratory Test Results: Real-World Study Using the eHealth Impact Questionnaire. JMIR Form Res. 2020;4(3):e17060.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKang H. Sample size determination and power analysis using the G*Power software. J Educ Eval Health Prof. 2021;18:17.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide 131. Med Teach. 2020;42(8):846\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHolzel LP, et al. Usefulness scale for patient information material (USE) - development and psychometric properties. BMC Med Inf Decis Mak. 2015;15:34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee C, et al. Generalized Anxiety Disorder 7-Item (GAD-7) Scores in Medically Authorized Cannabis Patients-Ontario and Alberta, Canada. Can J Psychiatry. 2022;67(6):470\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eManea L, Gilbody S, McMillan D. Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis. CMAJ. 2012;184(3):E191\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShe Z et al. Three Versions of the Perceived Stress Scale: Psychometric Evaluation in a Nationally Representative Sample of Chinese Adults during the COVID-19 Pandemic. Int J Environ Res Public Health, 2021. 18(16).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhazaal Y, et al. Brief DISCERN, six questions for the evaluation of evidence-based content of health-related websites. Patient Educ Couns. 2009;77(1):33\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eReadability formulas tool.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eScolarius tool.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang LW, et al. Assessing readability formula differences with written health information materials: application, results, and recommendations. Res Social Adm Pharm. 2013;9(5):503\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWittink H, Oosterhaven J. Patient education and health literacy. Musculoskelet Sci Pract. 2018;38:120\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoureanu M, et al. Evaluation of online, publicly available cancer-related educational and self-management resources for symptom management. Psycho-oncology. 2021;30(11):1884\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKher A, Johnson S, Griffith R. \u003cem\u003eReadability Assessment of Online Patient Education Material on Congestive Heart Failure.\u003c/em\u003e Adv Prev Med, 2017. 2017: p. 9780317.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePiolat AB, Chung RJ, Davids CK, Pennebaker M. J.W., \u003cem\u003eLa version fran\u0026ccedil;aise du dictionnaire pour le LIWC.\u003c/em\u003e 2011.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eThe Development and Psychometric Properties of LIWC-22\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eAnalysis tone tool.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOktay LA, et al. Factors Affecting Engagement in Web-Based Health Care Patient Information: Narrative Review of the Literature. J Med Internet Res. 2021;23(9):e19896.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLim MSC, et al. Young Adults' Use of Different Social Media Platforms for Health Information: Insights From Web-Based Conversations. J Med Internet Res. 2022;24(1):e23656.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMadanian S, et al. Patients' perspectives on digital health tools. PEC Innov. 2023;2:100171.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRooney MK, et al. Readability of Patient Education Materials From High-Impact Medical Journals: A 20-Year Analysis. J Patient Exp. 2021;8:2374373521998847.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFriedman DB, Hoffman-Goetz L. A systematic review of readability and comprehension instruments used for print and web-based cancer information. Health Educ Behav. 2006;33(3):352\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSand-Jecklin K. The impact of medical terminology on readability of patient education materials. J Community Health Nurs. 2007;24(2):119\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-informatics-and-decision-making","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"midm","sideBox":"Learn more about [BMC Medical Informatics and Decision Making](http://bmcmedinformdecismak.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/midm/default.aspx","title":"BMC Medical Informatics and Decision Making","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"preoperative information, patient education, audiovisual information material, thyroidectomy, e-health, shared decision-making","lastPublishedDoi":"10.21203/rs.3.rs-7309071/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7309071/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTo facilitate shared decision-making, patients increasingly rely on online platforms for health-related information. While thyroid diseases are common, the quality of available thyroid-related information varies. This study comprehensively evaluated a new audiovisual information material developed by Medtronic for patients with surgical thyroid disease in English and French.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eData were collected from patients at baseline (t1), after accessing the French version of Medtronic\u0026rsquo;s Butterfly platform but before surgery (t2), and three weeks post-surgery (t3). Patients assessed the material\u0026rsquo;s usefulness (USE), impact (eHIQ) and quality (Brief DISCERN), provided feedback on its content using a custom debriefing questionnaire, and self-reported on their anxiety (GAD-7), depression (PHQ-9) and stress (PSS-14). We assessed both versions for readability (FRES, FKGL, SMOG, GFI, and Scolarius); understandability and actionability (PEMAT-A/V); linguistic aspects (LIWC-22) and tone style (YesChat Tone Analyzer). In addition to conducting quantitative and qualitative analyses of the respective datasets, triangulation was used to integrate both approaches.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf 26 patients enrolled, 24 (t2), and 22 (t3) completed the study; both benign and malignant/potentially malignant surgical indications were represented. The material\u0026rsquo;s scores regarding usefulness and impact at t2 were both significantly above the respective predefined thresholds. Consistently, qualitative analysis showed that most participants found the material useful or very useful. Whereas anxiety and depression scores were low across t1-t3, levels of stress were consistently high, and a negative correlation between USE and GAD-7 scores suggested that greater perceived usefulness is associated with lower anxiety levels. Even though readability scores for both languages indicated higher complexity than the generally recommended 6th -8th grade level, neither the quantitative nor the qualitative feedback of patients indicated challenges with the material\u0026rsquo;s language. Assessment of the material by five investigators showed very good understandability and excellent actionability. Linguistic analysis showed a somewhat higher complexity of the French version; for both versions, tone analysis reported a clear, approachable, and professional style, with direct and informative content, using generally simple language. Finally, participants suggested slight improvements, especially regarding online navigation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eMedtronic\u0026rsquo;s Butterfly platform is a high-quality information source to aid shared decision-making in patients with surgical thyroid diseases.\u003c/p\u003e","manuscriptTitle":"Comprehensive evaluation of Medtronic’s Butterfly platform, a new audiovisual information material for patient education and shared decision-making in surgical thyroid disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-17 14:12:42","doi":"10.21203/rs.3.rs-7309071/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-23T07:14:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-23T00:49:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-30T20:43:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320069299078600238948393281686681378461","date":"2025-08-10T12:44:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277368177281627008784962135090723747781","date":"2025-08-08T12:42:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-08T12:17:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-08T07:15:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-08T07:13:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Informatics and Decision Making","date":"2025-08-06T10:53:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-informatics-and-decision-making","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"midm","sideBox":"Learn more about [BMC Medical Informatics and Decision Making](http://bmcmedinformdecismak.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/midm/default.aspx","title":"BMC Medical Informatics and Decision Making","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e9f2def2-49bf-4e72-aebe-c8b96279a1a2","owner":[],"postedDate":"August 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T15:59:58+00:00","versionOfRecord":{"articleIdentity":"rs-7309071","link":"https://doi.org/10.1186/s12911-026-03526-w","journal":{"identity":"bmc-medical-informatics-and-decision-making","isVorOnly":false,"title":"BMC Medical Informatics and Decision Making"},"publishedOn":"2026-04-29 15:57:20","publishedOnDateReadable":"April 29th, 2026"},"versionCreatedAt":"2025-08-17 14:12:42","video":"","vorDoi":"10.1186/s12911-026-03526-w","vorDoiUrl":"https://doi.org/10.1186/s12911-026-03526-w","workflowStages":[]},"version":"v1","identity":"rs-7309071","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7309071","identity":"rs-7309071","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}